Nationwide trends in use and timeliness of diagnostic coronary angiography in acute coronary syndromes from 2005 to 2011: Does distance to invasive heart centres matter?

PubMed

Hansen, Kim W; Sørensen, Rikke; Madsen, Mette; Madsen, Jan K; Jensen, Jan S; von Kappelgaard, Lene M; Mortensen, Poul E; Galatius, Søren

2015-08-01

To examine trends in the use of diagnostic coronary angiography according to distance from home to the nearest invasive heart centre following implementation of fast-track protocols and extensive pre-hospital triaging of acute coronary syndrome patients. We performed a register-based cohort study of all patients admitted to Danish hospitals with incident acute coronary syndrome in 2005-2011. Diagnostic coronary angiography within 60 days of admission was investigated according to distance tertiles (DTs) calculated as range from each patient's home to the nearest invasive heart centre (short DT: <22 km, medium DT: 22-65 km, long DT: >65 km). Cox proportional hazards models were applied.Among the 52,409 patients included, diagnostic coronary angiography was increasingly used during 2005-2011 (short DT: 76% to 81%; medium DT: 74% to 81%; long DT: 69% to 78%; all p-values for trend <0.001). Using the short DT as reference the adjusted hazard ratios for medium DT were 0.87 (0.84-0.89) for 2005-2007, 0.94 (0.90-0.98) for 2008-2009 and 0.94 (0.90-0.98) for 2010-2011. Corresponding figures for long DT were 0.74 (0.72-0.76) for 2005-2007, 0.87 (0.83-0.90) for 2008-2009 and 0.94 (0.90-0.98) for 2010-2011. Length of hospital stay, time to coronary angiography, and 60-day mortality decreased in all DT. This nationwide study found significant increases in diagnostic coronary angiography use over time in incident acute coronary syndrome patients with a relatively larger increase in patients residing farthest from an invasive heart centre. Additionally, selected quality of care measures improved in the entire cohort, suggesting a benefit of national clinical protocols. © The European Society of Cardiology 2014.

Chaotic behavior of the coronary circulation.

PubMed

Trzeciakowski, Jerome; Chilian, William M

2008-05-01

The regulation of the coronary circulation is a complex paradigm in which many inputs that influence vasomotor tone have to be integrated to provide the coronary vasomotor adjustments to cardiac metabolism and to perfusion pressure. We hypothesized that the integration of many disparate signals that influence membrane potential of smooth muscle cells, calcium sensitivity of contractile filaments, receptor trafficking result in complex non-linear characteristics of coronary vasomotion. To test this hypothesis, we measured an index of vasomotion, flowmotion, the periodic fluctuations of flow that reflect dynamic changes in resistances in the microcirculation. Flowmotion was continuously measured in periods ranging from 15 to 40 min under baseline conditions, during antagonism of NO synthesis, and during combined purinergic and NOS antagonism in the beating heart of anesthetized open-chest dogs. Flowmotion was measured in arterioles ranging from 80 to 135 microm in diameter. The signals from the flowmotion measurements were used to derive quantitative indices of non-linear behavior: power spectra, chaotic attractors, correlation dimensions, and the sum of the Lyapunov exponents (Kolmogorov-Sinai entropy), which reflects the total chaos and unpredictability of flowmotion. Under basal conditions, the coronary circulation demonstrated chaotic non-linear behavior with a power spectra showing three principal frequencies in flowmotion. Blockade of nitric oxide synthase or antagonism of purinergic receptors did not affect the correlation dimensions, but significantly increased the Kolmogorov-Sinai entropy, altered the power spectra of flowmotion, and changed the nature of the chaotic attractor. These changes are consistent with the view that certain endogenous controls, nitric oxide and various purines (AMP, ADP, ATP, adenosine) make the coronary circulation more predictable, and that blockade of these controls makes the control of flow less predictable and more chaotic.

Exercise for vasomotor menopausal symptoms.

PubMed

Daley, A; MacArthur, C; Mutrie, N; Stokes-Lampard, H

2007-10-17

Evidence suggests that a high proportion of perimenopausal and early postmenopausal women will experience some menopause symptoms, hot flushes being the most common. The effects caused by falling levels of estrogen may be alleviated by hormone replacement therapy (HRT) but there has been a marked global decline in the prescription and use of HRT due to concerns about the risks and benefits of HRT; consequently many women are now seeking alternatives. As large numbers of women are choosing not to take HRT, it is increasingly important to identify evidence based lifestyle modifications, which can have a positive effect on menopausal symptoms. To examine the effectiveness of any type of exercise intervention in the management of vasomotor menopausal symptoms (hot flushes and night sweats) in perimenopausal and postmenopausal women. Searches of the following electronic bibliographic databases were performed to identify randomised controlled trials: The Cochrane Library (CENTRAL) (Wiley Internet interface) 2006 Issue 2, MEDLINE (Ovid) 1966-May week 4 2006, EMBASE (Ovid) 1980-week 21 2006, PsycINFO (Ovid) 1967-May week 5 2006, Science Citation Index and Social Science Citation Index (Web of Science) 1900-June 2006 and 1956-June 2006 respectively, CINAHL (Ovid) 1982-May week 4 2006, SPORT Discus (ERL WebSPIRS) 1830-2006/04. Randomised controlled trials (RCTs) in which any type of exercise intervention was compared to other treatments or no treatment in the management of menopausal vasomotor symptoms in symptomatic perimenopausal and postmenopausal women. Nineteen reports were deemed potentially eligible, but of these only one met the inclusion criteria and three authors independently extracted data from this trial. Only one very small trial, which compared exercise with HRT, was available for inclusion in this review. Based on within-group analyses the study authors concluded that both interventions were effective in reducing vasomotor symptoms. Between-group trial

[Predictors of the use of the early invasive strategy in women with non-ST-elevation acute coronary syndrome].

PubMed

de Miguel-Balsa, E; Baeza-Román, A; Pino-Izquierdo, K; Latour-Pérez, J; Coves-Orts, F J; Alcoverro-Pedrola, J M; Pavía-Pesquera, M C; Felices-Abad, F; Calvo-Embuena, R

2014-11-01

To identify determinants associated to an early invasive strategy in women with acute coronary syndromes without ST elevation (NSTE-ACS). A retrospective cohort study was made. Crude and adjusted analysis of the performance of the early invasive strategy using logistic regression. Coronary Units enrolled in 2010 - 2011 in the ARIAM-SEMICYUC registry. A total of 440 women with NSTE-ACS were studied. Sixteen patients were excluded due to insufficient data, together with 58 patients subjected to elective coronary angiography (> 72 h). Demographic parameters, coronary risk factors, previous medication, comorbidity. Clinical, laboratory, hemodynamic and electrocardiographic data of the episode. Women treated conservatively were of older age, had oral anticoagulation, diabetes, previous coronary lesions, and heart failure (p<0.005), increased baseline bleeding and ischemic risk (p=0.05) and a higher heart rate upon admission (p<0.05). After adjustment, only age > 80 years (OR 0.48, 95% CI 0.27 to 0.82, p=0.009), known coronary lesions (OR 0.47, 95% CI 0.26-0.84, p=0.011), and heart rate (OR 0.98, 95% CI 0.97-0.99, p=0.003) were independently associated to conservative treatment. Smoking (OR 2.50, 95% CI 1.20 to 5.19, p=0.013) and high-risk electrocardiogram (OR 2.96, 95% CI 1.72 to 4.97, p<0.001) were associated to the early invasive strategy. The exclusion of early deaths (<24 h) did not alter these results. In women with NSTE ACS, smoking and a high-risk electrocardiogram upon admission were independent factors associated to the early invasive strategy. Previous coronary lesions, age > 80 years and increased heart rate were independent factors associated to conservative treatment. Copyright © 2012 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

[Early invasive strategy in diabetic patients with non-ST-segment elevation acute coronary syndromes].

PubMed

Baeza Román, Anna; Latour Pérez, Jaime; de Miguel Balsa, Eva; Pino Izquierdo, Karel; Coves Orts, Francisco Javier; García Ochando, Luis; de la Torre Fernández, Maria José

2014-05-20

In the management of non-ST-segment elevation acute coronary syndromes (NSTE-ACS), several studies have shown a reduction in mortality with the use of an invasive strategy in high-risk patients, including diabetic patients. Paradoxically, other studies have shown an under-utilization of this invasive strategy in these patients. The aim of this study is to determine the characteristics of patients managed conservatively and identify determinants of the use of invasive or conservative strategy. Retrospective cohort study conducted in diabetic patients with NSTE-ACS included in the ARIAM-SEMICYUC registry (n=531) in 2010 and 2011. We performed crude and adjusted unconditional logistic regression. We analyzed 531 diabetic patients, 264 (49.7%) of which received invasive strategy. Patients managed conservatively were a subgroup characterized by older age and cardiovascular comorbidity, increased risk of bleeding and the absence of high-risk electrocardiogram (ECG). In diabetic patients with NSTE-ACS, independent predictors associated with conservative strategy were low-risk ECG, initial Killip class>1, high risk of bleeding and pretreatment with clopidogrel. The fear of bleeding complications or advanced coronary lesions could be the cause of the underutilization of an invasive strategy in diabetic patients with NSTE-ACS. Copyright © 2012 Elsevier España, S.L. All rights reserved.

Latest-generation catheterization systems enable invasive submillisievert coronary angiography.

PubMed

Kuon, E; Weitmann, K; Hummel, A; Dörr, M; Reffelmann, T; Riad, A; Busch, M C; Felix, S B; Hoffmann, W; Empen, K

2015-05-01

The radiation risk of patients undergoing invasive cardiology remains considerable and includes skin injuries and cancer. To date, submillisievert coronary angiography has not been considered feasible. In 2011, we compared results from 100 consecutive patients undergoing elective coronary angiography using the latest-generation flat-panel angiography system (FPS) with results from examinations by the same operator using 106 historic controls with a conventional image-intensifier system (IIS) that was new in 2002. The median patient exposure parameters were measured as follows: dose-area product (DAP) associated with radiographic cine acquisitions (DAP(R)) and fluoroscopy (DAP(F)) scenes, radiographic frames and runs, and cumulative exposure times for radiography and fluoroscopy. On the FPS as compared to the traditional IIS, radiographic detector entrance dose levels were reduced from 164 to 80 nGy/frame and pulse rates were lowered from 12.5/s to 7.5/s during radiography and from 25/s to 4/s during fluoroscopy. The cardiologist's performance patterns remained comparable over the years: fluoroscopy time was constant and radiography time even slightly increased. Overall patient DAP decreased from 7.0 to 2.4 Gy × cm(2); DAP(R), from 4.2 to 1.7 Gy × cm(2); and DAP(F), from 2.8 to 0.6 Gy × cm(2). Time-adjusted DAP(R)/s decreased from 436 to 130 mGy × cm(2) and DAP(F)/s, from 21.6 to 4.4 mGy × cm(2). Cumulative patient skin dose with the FPS amounted to 67 mGy, and the median (interquartile range) of effective dose was 0.5 (0.3 … 0.7) mSv. Consistent application of radiation-reducing techniques with the latest-generation flat-panel systems enables submillisievert coronary angiography in invasive cardiology.

Cost analysis of non-invasive fractional flow reserve derived from coronary computed tomographic angiography in Japan.

PubMed

Kimura, Takeshi; Shiomi, Hiroki; Kuribayashi, Sachio; Isshiki, Takaaki; Kanazawa, Susumu; Ito, Hiroshi; Ikeda, Shunya; Forrest, Ben; Zarins, Christopher K; Hlatky, Mark A; Norgaard, Bjarne L

2015-01-01

Percutaneous coronary intervention (PCI) based on fractional flow reserve (FFRcath) measurement during invasive coronary angiography (CAG) results in improved patient outcome and reduced healthcare costs. FFR can now be computed non-invasively from standard coronary CT angiography (cCTA) scans (FFRCT). The purpose of this study is to determine the potential impact of non-invasive FFRCT on costs and clinical outcomes of patients with suspected coronary artery disease in Japan. Clinical data from 254 patients in the HeartFlowNXT trial, costs of goods and services in Japan, and clinical outcome data from the literature were used to estimate the costs and outcomes of 4 clinical pathways: (1) CAG-visual guided PCI, (2) CAG-FFRcath guided PCI, (3) cCTA followed by CAG-visual guided PCI, (4) cCTA-FFRCT guided PCI. The CAG-visual strategy demonstrated the highest projected cost ($10,360) and highest projected 1-year death/myocardial infarction rate (2.4 %). An assumed price for FFRCT of US $2,000 produced equivalent clinical outcomes (death/MI rate: 1.9 %) and healthcare costs ($7,222) for the cCTA-FFRCT strategy and the CAG-FFRcath guided PCI strategy. Use of the cCTA-FFRCT strategy to select patients for PCI would result in 32 % lower costs and 19 % fewer cardiac events at 1 year compared to the most commonly used CAG-visual strategy. Use of cCTA-FFRCT to select patients for CAG and PCI may reduce costs and improve clinical outcome in patients with suspected coronary artery disease in Japan.

Computed tomography versus invasive coronary angiography: design and methods of the pragmatic randomised multicentre DISCHARGE trial.

PubMed

Napp, Adriane E; Haase, Robert; Laule, Michael; Schuetz, Georg M; Rief, Matthias; Dreger, Henryk; Feuchtner, Gudrun; Friedrich, Guy; Špaček, Miloslav; Suchánek, Vojtěch; Fuglsang Kofoed, Klaus; Engstroem, Thomas; Schroeder, Stephen; Drosch, Tanja; Gutberlet, Matthias; Woinke, Michael; Maurovich-Horvat, Pál; Merkely, Béla; Donnelly, Patrick; Ball, Peter; Dodd, Jonathan D; Quinn, Martin; Saba, Luca; Porcu, Maurizio; Francone, Marco; Mancone, Massimo; Erglis, Andrejs; Zvaigzne, Ligita; Jankauskas, Antanas; Sakalyte, Gintare; Harań, Tomasz; Ilnicka-Suckiel, Malgorzata; Bettencourt, Nuno; Gama-Ribeiro, Vasco; Condrea, Sebastian; Benedek, Imre; Čemerlić Adjić, Nada; Adjić, Oto; Rodriguez-Palomares, José; Garcia Del Blanco, Bruno; Roditi, Giles; Berry, Colin; Davis, Gershan; Thwaite, Erica; Knuuti, Juhani; Pietilä, Mikko; Kępka, Cezary; Kruk, Mariusz; Vidakovic, Radosav; Neskovic, Aleksandar N; Díez, Ignacio; Lecumberri, Iñigo; Geleijns, Jacob; Kubiak, Christine; Strenge-Hesse, Anke; Do, The-Hoang; Frömel, Felix; Gutiérrez-Ibarluzea, Iñaki; Benguria-Arrate, Gaizka; Keiding, Hans; Katzer, Christoph; Müller-Nordhorn, Jacqueline; Rieckmann, Nina; Walther, Mario; Schlattmann, Peter; Dewey, Marc

2017-07-01

More than 3.5 million invasive coronary angiographies (ICA) are performed in Europe annually. Approximately 2 million of these invasive procedures might be reduced by noninvasive tests because no coronary intervention is performed. Computed tomography (CT) is the most accurate noninvasive test for detection and exclusion of coronary artery disease (CAD). To investigate the comparative effectiveness of CT and ICA, we designed the European pragmatic multicentre DISCHARGE trial funded by the 7th Framework Programme of the European Union (EC-GA 603266). In this trial, patients with a low-to-intermediate pretest probability (10-60 %) of suspected CAD and a clinical indication for ICA because of stable chest pain will be randomised in a 1-to-1 ratio to CT or ICA. CT and ICA findings guide subsequent management decisions by the local heart teams according to current evidence and European guidelines. Major adverse cardiovascular events (MACE) defined as cardiovascular death, myocardial infarction and stroke as a composite endpoint will be the primary outcome measure. Secondary and other outcomes include cost-effectiveness, radiation exposure, health-related quality of life (HRQoL), socioeconomic status, lifestyle, adverse events related to CT/ICA, and gender differences. The DISCHARGE trial will assess the comparative effectiveness of CT and ICA. • Coronary artery disease (CAD) is a major cause of morbidity and mortality. • Invasive coronary angiography (ICA) is the reference standard for detection of CAD. • Noninvasive computed tomography angiography excludes CAD with high sensitivity. • CT may effectively reduce the approximately 2 million negative ICAs in Europe. • DISCHARGE addresses this hypothesis in patients with low-to-intermediate pretest probability for CAD.

Pooled Analysis of Six Pharmacologic and Nonpharmacologic Interventions for Vasomotor Symptoms.

PubMed

Guthrie, Katherine A; LaCroix, Andrea Z; Ensrud, Kristine E; Joffe, Hadine; Newton, Katherine M; Reed, Susan D; Caan, Bette; Carpenter, Janet S; Cohen, Lee S; Freeman, Ellen W; Larson, Joseph C; Manson, JoAnn E; Rexrode, Kathy; Skaar, Todd C; Sternfeld, Barbara; Anderson, Garnet L

2015-08-01

To describe the effects of six interventions for menopausal vasomotor symptoms relative to control in a pooled analysis, facilitating translation of the results for clinicians and symptomatic women. The Menopause Strategies: Finding Lasting Answers for Symptoms and Health network tested these interventions in three randomized clinical trials. An analysis of pooled individual-level data from three randomized clinical trials is presented. Participants were 899 perimenopausal and postmenopausal women with at least 14 bothersome vasomotor symptoms per week. Interventions included 10-20 mg escitalopram per day, nonaerobic yoga, aerobic exercise, 1.8 g per day omega-3 fatty acid supplementation, 0.5 mg low-dose oral 17-beta-estradiol (E2) per day, and 75 mg low-dose venlafaxine XR per day. The main outcome measures were changes from baseline in mean daily vasomotor symptom frequency and bother during 8-12 weeks of treatment. Linear regression models estimated differences in outcomes between each intervention and corresponding control group adjusted for baseline characteristics. Models included trial-specific intercepts, effects of the baseline outcome measure, and time. The 8-week reduction in vasomotor symptom frequency from baseline relative to placebo was similar for escitalopram at -1.4 per day (95% confidence interval [CI] -2.7 to -0.2), low-dose E2 at -2.4 (95% CI -3.4 to -1.3), and venlafaxine at -1.8 (95% CI -2.8 to -0.8); vasomotor symptom bother reduction was minimal and did not vary across these three pharmacologic interventions (mean -0.2 to -0.3 relative to placebo). No effects on vasomotor symptom frequency or bother were seen with aerobic exercise, yoga, or omega-3 supplements. These analyses suggest that escitalopram, low-dose E2, and venlafaxine provide comparable, modest reductions in vasomotor symptom frequency and bother among women with moderate hot flushes. ClinicalTrials.gov, www.clinicaltrials.gov, NCT00894543 (MsFLASH 01), NCT01178892 (MsFLASH 02

Early Invasive Strategy and In-Hospital Survival Among Diabetics With Non-ST-Elevation Acute Coronary Syndromes: A Contemporary National Insight.

PubMed

Mahmoud, Ahmed N; Elgendy, Islam Y; Mansoor, Hend; Wen, Xuerong; Mojadidi, Mohammad K; Bavry, Anthony A; Anderson, R David

2017-03-18

There are limited data on the merits of an early invasive strategy in diabetics with non-ST-elevation acute coronary syndrome, with unclear influence of this strategy on survival. The aim of this study was to evaluate the in-hospital survival of diabetics with non-ST-elevation acute coronary syndrome treated with an early invasive strategy compared with an initial conservative strategy. The National Inpatient Sample database, years 2012-2013, was queried for diabetics with a primary diagnosis of non-ST-elevation acute coronary syndrome defined as either non-ST-elevation myocardial infarction or unstable angina (unstable angina). An early invasive strategy was defined as coronary angiography±revascularization within 48 hours of admission. Propensity scores were used to assemble a cohort managed with either an early invasive or initial conservative strategy balanced on >50 baseline characteristics and hospital presentations. Incidence of in-hospital mortality was compared in both groups. In a cohort of 363 500 diabetics with non-ST-elevation acute coronary syndrome, 164 740 (45.3%) were treated with an early invasive strategy. Propensity scoring matched 21 681 diabetics in both arms. Incidence of in-hospital mortality was lower with an early invasive strategy in both the unadjusted (2.0% vs 4.8%; odds ratio [OR], 0.41; 95% CI, 0.39-0.42; P <0.0001) and propensity-matched models (2.2% vs 3.8%; OR, 0.57; 95% CI, 0.50-0.63; P <0.0001). The benefit was observed across various subgroups, except for patients with unstable angina ( P interaction =0.02). An early invasive strategy may be associated with a lower incidence of in-hospital mortality in patients with diabetes. The benefit of this strategy appears to be superior in patients presenting with non-ST-elevation myocardial infarction compared with unstable angina. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Non-invasive coronary angiography for patients with acute atypical chest pain discharged after negative screening including maximal negative treadmill stress test. A prospective study.

PubMed

Bonello, L; Armero, S; Jacquier, A; Com, O; Sarran, A; Sbragia, P; Panuel, M; Arques, S; Paganelli, F

2009-05-01

Among patients admitted in the emergency department for acute atypical chest pain those with an acute coronary syndrome (ACS) who are mistakenly discharged home have high mortality. A recent retrospective study has demonstrated that multislice computed tomography (MSCT) coronary angiography could improve triage of these patients. We aimed to prospectively confirm these data on patients with a negative screening including maximal treadmill stress. 30 patients discharged from the emergency department after negative screening for an ACS were included. All patients underwent MSCT angiography of the coronary artery. Patients with coronary atheroma on MSCT had an invasive coronary angiography to confirm these findings. Seven patients (23%) had obstructive coronary artery disease on MSCT. Invasive coronary angiography (ICA) confirmed the diagnosis in all patients. In patients with no previously known coronary artery disease admitted to the emergency department with atypical acute chest pain and discharged after negative screening, including maximal treadmill stress test, MSCT coronary angiography is useful for the diagnosis of obstructive coronary artery disease.

NIKOS II - A System For Non-Invasive Imaging Of Coronary Arteries

NASA Astrophysics Data System (ADS)

Dix, Wolf-Rainer; Engelke, Klaus; Heintze, Gerhard; Heuer, Joachim; Graeff, Walter; Kupper, Wolfram; Lohmann, Michael; Makin, I.; Moechel, Thomas; Reumann, Reinhold; Stellmaschek, Karl-Heinz

1989-05-01

This paper presents results of the initial in-vivo investigations with the system NIKOS II (NIKOS = Nicht-invasive Koronarangiographie mit Synchrotronstrahlung), an advanced version of NIKOS I which was developed since 1981. Aim of the work is to be able to visualize coronary arteries down to 1mm diameter with an iodine mass density of lmg/cm2, thus allowing non-invasive investigations by intravenous injection of the contrast agent. For this purpose Digital Subtraction Angiography (DSA) in energy subtraction mode (dichromography) is employed. The two images for subtraction are taken at photon energies just below and above the iodine K-edge (33.17keV) After subtraction the background contrast from bone and soft tissue is suppressed and the iodinated structures are strongly enhanced because of the abrupt change of absorption at the K-edge. The two monoenergetic beams are filtered out of a synchrotron radiation beam by a crystal monochromator and measured with a two line detector. One scan (two images) lasts between 250ms (final version) and ls (at present ). The images from the in-vivo investigations of dogs have been promising. The right coronary artery (diameter 1.5mm) was clearly visible. With application of better image processing algorithms the images illustrated in this paper have a definite potential for improvement.

The risk of coronary artery disease estimated non-invasively in patients with essential hypertension environmentally exposed to cigarette smoke.

PubMed

Gać, Paweł; Jaźwiec, Przemysław; Poręba, Małgorzata; Mazur, Grzegorz; Pawlas, Krystyna; Sobieszczańska, Małgorzata; Poręba, Rafał

2017-12-01

The relationship between environmental exposure of non-smokers to cigarette smoke and the coronary artery calcium scores has not been sufficiently documented. The aim of the study was to identify the relationship between environmental exposure to cigarette smoke and the risk of coronary artery disease (CAD) estimated non-invasively through measurement of coronary artery calcium score by computed tomography in patients with essential hypertension. The study was conducted on 67 patients with essential hypertension, non-smokers environmentally exposed to cigarette smoke (group A) and on 67 patients with essential hypertension, non-smokers not exposed to cigarette smoke (group B), selected using the case to case. Environmental exposure to cigarette smoke was evaluated using a questionnaire. The risk of development of coronary artery disease was estimated non-invasively through measurement of coronary artery calcium score (CA CS ) by computed tomography. Group A was characterised by significantly higher CA CS and left anterior descending (LAD CS ) calcium scores than group B. Compared to group B, group A had significantly higher percentage of patients with significant risk of CAD estimated on the basis of CA CS values, and significantly lower percentage of patients with practically no risk of CAD estimated with the same method. Advanced age, peripheral artery diseases and environmental exposure to cigarette smoke are independent risk factors associated with increased CA CS and LAD CS values. In addition, higher BMI and hypercholesterolemia are independent risk factors for increased values of LAD CS . In patients with essential hypertension environmental exposure to cigarette smoke may result in elevated risk of coronary artery disease estimated non-invasively through measurement of coronary artery calcium score by computed tomography. Copyright © 2017 Elsevier B.V. All rights reserved.

Pravastatin and endothelium dependent vasomotion after coronary angioplasty: the PREFACE trial.

PubMed

Mulder, H J; Schalij, M J; Kauer, B; Visser, R F; van Dijkman, P R; Jukema, J W; Zwinderman, A H; Bruschke, A V

2001-11-01

To test the hypothesis that the 3-hydroxy-3-methylglutaryl coenzyme-A reductase inhibitor pravastatin ameliorates endothelium mediated responses of dilated coronary segments: the PREFACE (pravastatin related effects following angioplasty on coronary endothelium) trial. A double blind, randomised, placebo controlled, multicentre study. Four hospitals in the Netherlands. 63 non-smoking, non-hypercholesterolaemic patients scheduled for elective balloon angioplasty (pravastatin 34, placebo 29). The effects of three months of pravastatin treatment (40 mg daily) on endothelium dependent vasomotor function were studied. Balloon angioplasty was undertaken one month after randomisation, and coronary vasomotor function tests using acetylcholine were performed two months after balloon angioplasty. The angiograms were analysed quantitatively. The efficacy measure was the acetylcholine induced change in mean arterial diameter, determined in the dilated segment and in an angiographically normal segment of an adjacent non-manipulated coronary artery. Increasing acetylcholine doses produced vasoconstriction in the dilated segments (p = 0.004) but not in the normal segments. Pravastatin did not affect the vascular response to acetylcholine in either the dilated segments (p = 0.09) or the non-dilated sites. Endothelium dependent vasomotion in normal segments was correlated with that in dilated segments (r = 0.47, p < 0.001). There were fewer procedure related events in the pravastatin group than in the placebo group (p < 0.05). Endothelium dependent vasomotion in normal segments is correlated with that in dilated segments. A significant beneficial effect of pravastatin on endothelial function could not be shown, but in the dilated segments there was a trend towards a beneficial treatment effect in the pravastatin group.

Developments in the invasive diagnostic–therapeutic cascade of women and men with acute coronary syndromes from 2005 to 2011: a nationwide cohort study

PubMed Central

Hansen, Kim Wadt; Soerensen, R; Madsen, M; Madsen, J K; Jensen, J S; von Kappelgaard, L M; Mortensen, P E; Galatius, S

2015-01-01

Objectives To investigate for trends in sex-related differences in the invasive diagnostic–therapeutic cascade in a population of patients with acute coronary syndromes (ACS). Design A nationwide cohort study. Setting Administrative and clinical registries covering all hospitalisations, invasive cardiac procedures and deaths in the Danish population of 5.6 million inhabitants. Participants We included 52 565 patients aged 30–90 years who were hospitalised with a first ACS from January 2005 to November 2011. Follow-up was 60 days from the day of index admission. Main outcome measures Diagnostic coronary angiography, percutaneous coronary intervention or coronary artery bypass within 60 days of index admission. Results Women constituted 36%, were older, had more comorbidity and were less likely to be admitted to a hospital with cardiac catheterisation facilities than men. Mortality rates were similar for both sexes. Diagnostic coronary angiography was performed less frequently on women compared with men, both within 1 day (31% vs 42%; p<0.001) and within 60 days (67% vs 80%; p<0.001), yielding adjusted female–male HRs of 0.83 (0.79–0.87) and 0.86 (0.84–0.89), respectively.Among the 39 677 patients undergoing coronary angiography, non-obstructive coronary artery disease was more frequent among women than men (22% vs 9%; p<0.001). Women were less likely to undergo percutaneous coronary intervention (58% vs 72%; p<0.001) and coronary artery bypass (6% vs 11%, p<0.001) within 60 days than men, yielding adjusted HRs of 0.96 (0.92–0.99) and 0.81 (0.74–0.89), respectively. The sex-related differences were not attenuated over time for any of the invasive cardiac procedures (p values for trend >0.05). Conclusions In this nationwide study, men were more likely to undergo an invasive approach than women when hospitalised with a first ACS—a difference persisting from 2005 to 2011. Future studies should focus on the potential mechanisms behind this

FMLP provokes coronary vasoconstriction and myocardial ischemia in rabbits

DOE Office of Scientific and Technical Information (OSTI.GOV)

Gillespie, M.N.; Booth, D.C.; Friedman, B.J.

Recent pathological studies of coronary arteries from humans with suspected coronary spasm have revealed an augmented intramural burden of inflammatory cells. To test the hypothesis than inappropriate activation of inflammatory cells participates in the evolution of coronary vasospasm, the present experiment employed a newly developed coronary arteriographic technique for use in pentobarbital-anesthetized rabbits to evaluate the coronary vasomotor actions of the nonselective inflammatory cell stimulant, N-formyl-L-methionyl-L-leucyl-L-phenylalanine (fMLP). In 10 of 10 animals, selective left intracoronary injection of 200 ng fMLP evoked profound left coronary narrowing accompanied in all cases by ST segment deviation and dysrhythmias. Thallium-201 scintigraphy demonstrated hypoperfusion ofmore » the left ventricular free wall and septum supplied by the spastic coronary artery. The fMLP-induced epicardial vasoconstriction, ischemic electrocardiogram (ECG) changes, and thallium perfusion defects were reversed by intravenous nitroglycerin. Neither the right coronary artery nor its distribution were influenced by left coronary injection of fMLP. Additional experiments in isolated, salt solution-perfused rabbit hearts demonstrated that fMLP failed to exert direct coronary vasoconstrictor effects. These observations indicate that the nonselective inflammatory cell stimulant, fMLP, provokes arteriographically demonstrable coronary spasm with attendant myocardial hypoperfusion and ischemic ECG changes in anesthetized rabbits. Such a model may be useful in exploring the dynamic role of inflammatory cells in development of coronary spasm.« less

10-Year Mortality Outcome of a Routine Invasive Strategy Versus a Selective Invasive Strategy in Non-ST-Segment Elevation Acute Coronary Syndrome: The British Heart Foundation RITA-3 Randomized Trial.

PubMed

Henderson, Robert A; Jarvis, Christopher; Clayton, Tim; Pocock, Stuart J; Fox, Keith A A

2015-08-04

The RITA-3 (Third Randomised Intervention Treatment of Angina) trial compared outcomes of a routine early invasive strategy (coronary arteriography and myocardial revascularization, as clinically indicated) to those of a selective invasive strategy (coronary arteriography for recurrent ischemia only) in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). At a median of 5 years' follow-up, the routine invasive strategy was associated with a 24% reduction in the odds of all-cause mortality. This study reports 10-year follow-up outcomes of the randomized cohort to determine the impact of a routine invasive strategy on longer-term mortality. We randomized 1,810 patients with NSTEACS to receive routine invasive or selective invasive strategies. All randomized patients had annual follow-up visits up to 5 years, and mortality was documented thereafter using data from the Office of National Statistics. Over 10 years, there were no differences in mortality between the 2 groups (all-cause deaths in 225 [25.1%] vs. 232 patients [25.4%]: p = 0.94; and cardiovascular deaths in 135 [15.1%] vs. 147 patients [16.1%]: p = 0.65 in the routine invasive and selective invasive groups, respectively). Multivariate analysis identified several independent predictors of 10-year mortality: age, previous myocardial infarction, heart failure, smoking status, diabetes, heart rate, and ST-segment depression. A modified post-discharge Global Registry of Acute Coronary Events (GRACE) score was used to calculate an individual risk score for each patient and to form low-risk, medium-risk, and high-risk groups. Risk of death within 10 years varied markedly from 14.4 % in the low-risk group to 56.2% in the high-risk group. This mortality trend did not depend on the assigned treatment strategy. The advantage of reduced mortality of routine early invasive strategy seen at 5 years was attenuated during later follow-up, with no evidence of a difference in outcome at 10 years

Early invasive versus non-invasive treatment in patients with non-ST-elevation acute coronary syndrome (FRISC-II): 15 year follow-up of a prospective, randomised, multicentre study.

PubMed

Wallentin, Lars; Lindhagen, Lars; Ärnström, Elisabet; Husted, Steen; Janzon, Magnus; Johnsen, Søren Paaske; Kontny, Frederic; Kempf, Tibor; Levin, Lars-Åke; Lindahl, Bertil; Stridsberg, Mats; Ståhle, Elisabeth; Venge, Per; Wollert, Kai C; Swahn, Eva; Lagerqvist, Bo

2016-10-15

The FRISC-II trial was the first randomised trial to show a reduction in death or myocardial infarction with an early invasive versus a non-invasive treatment strategy in patients with non-ST-elevation acute coronary syndrome. Here we provide a remaining lifetime perspective on the effects on all cardiovascular events during 15 years' follow-up. The FRISC-II prospective, randomised, multicentre trial was done at 58 Scandinavian centres in Sweden, Denmark, and Norway. Between June 17, 1996, and Aug 28, 1998, we randomly assigned (1:1) 2457 patients with non-ST-elevation acute coronary syndrome to an early invasive treatment strategy, aiming for revascularisation within 7 days, or a non-invasive strategy, with invasive procedures at recurrent symptoms or severe exercise-induced ischaemia. Plasma for biomarker analyses was obtained at randomisation. For long-term outcomes, we linked data with national health-care registers. The primary endpoint was a composite of death or myocardial infarction. Outcomes were compared as the average postponement of the next event, including recurrent events, calculated as the area between mean cumulative count-of-events curves. Analyses were done by intention to treat. At a minimum of 15 years' follow-up on Dec 31, 2014, data for survival status and death were available for 2421 (99%) of the initially recruited 2457 patients, and for other events after 2 years for 2182 (89%) patients. During follow-up, the invasive strategy postponed death or next myocardial infarction by a mean of 549 days (95% CI 204-888; p=0·0020) compared with the non-invasive strategy. This effect was larger in non-smokers (mean gain 809 days, 95% CI 402-1175; p interaction =0·0182), patients with elevated troponin T (778 days, 357-1165; p interaction =0·0241), and patients with high concentrations of growth differentiation factor-15 (1356 days, 507-1650; p interaction =0·0210). The difference was mainly driven by postponement of new myocardial infarction

EMAS position statement: Non-hormonal management of menopausal vasomotor symptoms.

PubMed

Mintziori, Gesthimani; Lambrinoudaki, Irene; Goulis, Dimitrios G; Ceausu, Iuliana; Depypere, Herman; Erel, C Tamer; Pérez-López, Faustino R; Schenck-Gustafsson, Karin; Simoncini, Tommaso; Tremollieres, Florence; Rees, Margaret

2015-07-01

To review non-hormonal therapy options for menopausal vasomotor symptoms. The current EMAS position paper aims to provide to provide guidance for managing peri- and postmenopausal women who cannot or do not wish to take menopausal hormone therapy (MHT). Literature review and consensus of expert opinion. Non-hormonal management of menopausal symptoms includes lifestyle modifications, diet and food supplements, non-hormonal medications and application of behavioral and alternative medicine therapies. There is insufficient or conflicting evidence to suggest that exercise, supplements or a diet rich in phytoestrogens are effective for vasomotor menopausal symptoms. Selective serotonin-reuptake inhibitors (SSRIs), serotonin norepinephrine-reuptake inhibitors (SNRIs) and gabapentin could be proposed as alternatives to MHT for menopausal symptoms, mainly hot flushes. Behavioral therapies and alternative medicine interventions have been tried, but the available evidence is still limited. A number of interventions for non-hormonal management of menopausal vasomotor symptoms are now available. For women who cannot or do not wish to take estrogens, non-hormonal management is now a realistic option. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Invasive strategy and frailty in very elderly patients with acute coronary syndromes.

PubMed

Llaó, Isaac; Ariza-Solé, Albert; Sanchis, Juan; Alegre, Oriol; López-Palop, Ramon; Formiga, Francesc; Marín, Francisco; Vidán, María T; Martínez-Sellés, Manuel; Sionis, Alessandro; Vives-Borrás, Miguel; Gómez-Hospital, Joan Antoni; Gómez-Lara, Josep; Roura, Gerard; Díez-Villanueva, Pablo; Núñez-Gil, Iván; Maristany, Jaume; Asmarats, Lluis; Bueno, Héctor; Abu-Assi, Emad; Cequier, Àngel

2018-04-03

Current guidelines recommend an early invasive strategy in patients with non-ST segment elevation acute coronary syndromes (NSTEACS). The role of an invasive strategy in frail elderly patients remains controversial. The LONGEVO-SCA registry included unselected NSTEACS patients aged ≥80 years. A geriatric assessment was performed during hospitalization, including frailty. We evaluated the impact of an invasive strategy during the admission on the incidence of cardiac death, reinfarction or new revascularisation at 6-months. From 531 patients included, 145 (27.3%) were frail. Mean age was 84.3 years. Most patients underwent an invasive strategy (407/531, 76.6%). Patients undergoing an invasive strategy were younger and had lower proportion of frailty (23.3% vs 40.3%, p<0.001). The incidence of cardiac events was more common in patients managed conservatively, after adjusting for confounding factors (sub-Hazard ratio (sHR) 2.32, 95% confidence interval (CI) 1.26-4.29, p=0.007). This association remained significant in non-frail patients (sHR 3.85, 95% CI 2.13-6.95, p=0.001), but was not significant in patients with established frailty criteria (sHR 1.40, 95% CI 0.72-2.75, p=0.325). The interaction invasive strategy-frailty was significant (p=0.032) Conclusions: An invasive strategy was independently associated with better outcomes in very elderly patients with NSTEACS. This association was different according to frailty status.

Non-invasive versus invasive management in patients with prior coronary artery bypass surgery with a non-ST segment elevation acute coronary syndrome: study design of the pilot randomised controlled trial and registry (CABG-ACS)

PubMed Central

Lee, Matthew M Y; Petrie, Mark C; Rocchiccioli, Paul; Simpson, Joanne; Jackson, Colette; Brown, Ammani; Corcoran, David; Mangion, Kenneth; McEntegart, Margaret; Shaukat, Aadil; Rae, Alan; Hood, Stuart; Peat, Eileen; Findlay, Iain; Murphy, Clare; Cormack, Alistair; Bukov, Nikolay; Balachandran, Kanarath; Papworth, Richard; Ford, Ian; Briggs, Andrew; Berry, Colin

2016-01-01

Introduction There is an evidence gap about how to best treat patients with prior coronary artery bypass grafts (CABGs) presenting with non-ST segment elevation acute coronary syndromes (NSTE-ACS) because historically, these patients were excluded from pivotal randomised trials. We aim to undertake a pilot trial of routine non-invasive management versus routine invasive management in patients with NSTE-ACS with prior CABG and optimal medical therapy during routine clinical care. Our trial is a proof-of-concept study for feasibility, safety, potential efficacy and health economic modelling. We hypothesise that a routine invasive approach in patients with NSTE-ACS with prior CABG is not superior to a non-invasive approach with optimal medical therapy. Methods and analysis 60 patients will be enrolled in a randomised clinical trial in 4 hospitals. A screening log will be prospectively completed. Patients not randomised due to lack of eligibility criteria and/or patient or physician preference and who give consent will be included in a registry. We will gather information about screening, enrolment, eligibility, randomisation, patient characteristics and adverse events (including post-discharge). The primary efficacy outcome is the composite of all-cause mortality, rehospitalisation for refractory ischaemia/angina, myocardial infarction and hospitalisation for heart failure. The primary safety outcome is the composite of bleeding, stroke, procedure-related myocardial infarction and worsening renal function. Health status will be assessed using EuroQol 5 Dimensions (EQ-5D) assessed at baseline and 6 monthly intervals, for at least 18 months. Trial registration number NCT01895751 (ClinicalTrials.gov). PMID:27110377

Pravastatin and endothelium dependent vasomotion after coronary angioplasty: the PREFACE trial

PubMed Central

Mulder, H; Schalij, M; Kauer, B; Visser, R; van Dijkman, P R M; Jukema, J; Zwinderman, A; Bruschke, A

2001-01-01

OBJECTIVE—To test the hypothesis that the 3-hydroxy-3-methylglutaryl coenzyme-A reductase inhibitor pravastatin ameliorates endothelium mediated responses of dilated coronary segments: the PREFACE (pravastatin related effects following angioplasty on coronary endothelium) trial.
DESIGN—A double blind, randomised, placebo controlled, multicentre study.
SETTING—Four hospitals in the Netherlands.
PATIENTS—63 non-smoking, non-hypercholesterolaemic patients scheduled for elective balloon angioplasty (pravastatin 34, placebo 29).
INTERVENTIONS—The effects of three months of pravastatin treatment (40 mg daily) on endothelium dependent vasomotor function were studied. Balloon angioplasty was undertaken one month after randomisation, and coronary vasomotor function tests using acetylcholine were performed two months after balloon angioplasty. The angiograms were analysed quantitatively.
MAIN OUTCOME MEASURES—The efficacy measure was the acetylcholine induced change in mean arterial diameter, determined in the dilated segment and in an angiographically normal segment of an adjacent non-manipulated coronary artery.
RESULTS—Increasing acetylcholine doses produced vasoconstriction in the dilated segments (p = 0.004) but not in the normal segments. Pravastatin did not affect the vascular response to acetylcholine in either the dilated segments (p = 0.09) or the non-dilated sites. Endothelium dependent vasomotion in normal segments was correlated with that in dilated segments (r = 0.47, p < 0.001). There were fewer procedure related events in the pravastatin group than in the placebo group (p < 0.05).
CONCLUSIONS—Endothelium dependent vasomotion in normal segments is correlated with that in dilated segments. A significant beneficial effect of pravastatin on endothelial function could not be shown, but in the dilated segments there was a trend towards a beneficial treatment effect in the pravastatin group.


Keywords: angioplasty

An Intervention to Control Vasomotor Symptoms for Advanced PC Patients on Hormone Therapy

DTIC Science & Technology

2014-08-01

Symptoms for Advanced PC Patients on Hormone Therapy PRINCIPAL INVESTIGATOR: Michael A. Diefenbach, Ph.D. CONTRACTING ORGANIZATION...Control Vasomotor Symptoms for Advanced PC Patients on Hormone Therapy 5a. CONTRACT NUMBER 5b. GRANT NUMBER W81XWH-11-1-0604 5c...NOTES 14. ABSTRACT Vasomotor Symptom (Hot Flashes) is a common side-effect of hormone therapy for prostate cancer survivors who experience a rising

Non-invasive coronary angiography: the clinical value of multi-slice computed tomography in the assessment of patients with prior coronary bypass surgery. Evaluating grafts and native vessels.

PubMed

von Kiedrowski, Helge; Wiemer, Marcus; Franzke, Krista; Preuss, Rainer; Vaske, Bernhard; Butz, Thomas; Oldenburg, Olaf; Bitter, Thomas; Mahmood, Khalid; Burchert, Wolfram; Horstkotte, Dieter; Langer, Christoph

2009-02-01

Contrast enhanced multi-slice computed tomography (MSCT) is the leading modality in non-invasive coronary angiography (CTA) today. We investigated MSCT based assessment of coronary artery bypass grafts (CABG) by analyzing assets and drawbacks of CTA in order to define demands on latest technology. In a clinical setting 39 CABG patients (69.2 +/- 1.4 years; male n = 36) underwent CTA (collimation 16 x 0.75 mm, contrast medium 100 ml; 320 mAs, 120 KV). Ninety-seven CABG (61 venous, 36 arterial grafts) were evaluated. A subgroup of 18 patients underwent additional invasive coronary angiography (CA). CTA for CABG assessment resulted in an overall sensitivity (sens.) of 100%, specificity (spec.) of 92.4% and positive and negative predictive values (PPV, NPV) of 60% and 100%, respectively. CABG anastomoses showed slightly inferior diagnostic accuracy than other CABG segments. Limitations in imaging quality caused 21% unevaluable segments of the CABG anastomoses. Evaluation of native vessel segments proximal and distal to the anastomoses resulted in a sens, spec, PPV and NPV of 57.5, 94.6, 92 and 67.3%, respectively. With 28.5% unevaluable segments, the native vessel segments showed serious limitations in imaging quality. Radiation exposure was 9.88 +/- 3.20 mSv (9.69 +/- 3.25 mSv male; 12.08 +/- 1.35 mSv female). 16-slice MSCT based CABG assessment offers sufficient diagnostic accuracy. However, focussing on the bypass anastomoses and the native revascularized coronary arteries, clinical value is limited.

Adopting an early invasive strategy for non-ST-elevation myocardial infarction: Analysis of the Portuguese Registry on Acute Coronary Syndromes.

PubMed

Morgado, Gonçalo; Pereira, Hélder; Caldeira, Daniel

2018-01-01

In patients with non-ST-elevation myocardial infarction (NSTEMI), the best timing for coronary angiography is not definitely established, although it is recognized that in high-risk patients it should be performed within the first 24 hours. The aim of this work was to describe the evolution over time of the use of an invasive strategy in the treatment of NSTEMI and in-hospital mortality. We performed a retrospective analysis of patients admitted with NSTEMI included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between 2002 and 2015. The annual proportion of patients undergoing coronary angiography and the time from admission to coronary angiography were assessed, as were changes in mortality and length of stay. A total of 18 639 patients with NSTEMI were included in the ProACS registry between 2002 and 2015. Over this period there were significant increases in the proportion of patients undergoing coronary angiography (from 52.0 to 83.6%) and angioplasty (from 23.3 to 53.0%), as well as in the proportion of patients who underwent coronary angiography within 24 hours of admission (from 21.0 to 48.1%). In-hospital mortality decreased in those aged over 74 years (from 9.5 to 3.7%) and in males. The progressive adoption of an invasive strategy, particularly an early one (within 24 hours), was accompanied by a reduction in in-hospital mortality. Since coronary angiography is performed late (>24 hours) in half of NSTEMI patients, these patients could benefit from initiatives similar to Stent for Life. Copyright © 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.

Early Invasive Versus Selective Strategy for Non-ST-Segment Elevation Acute Coronary Syndrome: The ICTUS Trial.

PubMed

Hoedemaker, Niels P G; Damman, Peter; Woudstra, Pier; Hirsch, Alexander; Windhausen, Fons; Tijssen, Jan G P; de Winter, Robbert J

2017-04-18

The ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes) trial compared early invasive strategy with a selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and an elevated cardiac troponin T. No long-term benefit of an early invasive strategy was found at 1 and 5 years. The aim of this study was to determine the 10-year clinical outcomes of an early invasive strategy versus a selective invasive strategy in patients with NSTE-ACS and an elevated cardiac troponin T. The ICTUS trial was a multicenter, randomized controlled clinical trial that included 1,200 patients with NSTE-ACS and an elevated cardiac troponin T. Enrollment was from July 2001 to August 2003. We collected 10-year follow-up of death, myocardial infarction (MI), and revascularization through the Dutch population registry, patient phone calls, general practitioners, and hospital records. The primary outcome was the 10-year composite of death or spontaneous MI. Additional outcomes included the composite of death or MI, death, MI (spontaneous and procedure-related), and revascularization. Ten-year death or spontaneous MI was not statistically different between the 2 groups (33.8% vs. 29.0%, hazard ratio [HR]: 1.12; 95% confidence interval [CI]: 0.97 to 1.46; p = 0.11). Revascularization occurred in 82.6% of the early invasive group and 60.5% in the selective invasive group. There were no differences in additional outcomes, except for a higher rate of death or MI in the early invasive group compared with the rates for the selective invasive group (37.6% vs. 30.5%; HR: 1.30; 95% CI: 1.07 to 1.58; p = 0.009), driven by a higher rate of procedure-related MI in the early invasive group (6.5% vs. 2.4%; HR: 2.82; 95% CI: 1.53 to 5.20; p = 0.001). In patients with NSTE-ACS and elevated cardiac troponin T levels, an early invasive strategy has no benefit over a selective invasive strategy in reducing the 10-year composite outcome of

Effects of intermittent theta burst stimulation on cerebral blood flow and cerebral vasomotor reactivity.

PubMed

Pichiorri, Floriana; Vicenzini, Edoardo; Gilio, Francesca; Giacomelli, Elena; Frasca, Vittorio; Cambieri, Chiara; Ceccanti, Marco; Di Piero, Vittorio; Inghilleri, Maurizio

2012-08-01

To determine whether intermittent theta burst stimulation influences cerebral hemodynamics, we investigated changes induced by intermittent theta burst stimulation on the middle cerebral artery cerebral blood flow velocity and vasomotor reactivity to carbon dioxide (CO(2)) in healthy participants. The middle cerebral artery flow velocity and vasomotor reactivity were monitored by continuous transcranial Doppler sonography. Changes in cortical excitability were tested by transcranial magnetic stimulation. In 11 healthy participants, before and immediately after delivering intermittent theta burst stimulation, we tested cortical excitability measured by the resting motor threshold and motor evoked potential amplitude over the stimulated hemisphere and vasomotor reactivity to CO(2) bilaterally. The blood flow velocity was monitored in both middle cerebral arteries throughout the experimental session. In a separate session, we tested the effects of sham stimulation under the same experimental conditions. Whereas the resting motor threshold remained unchanged before and after stimulation, motor evoked potential amplitudes increased significantly (P = .04). During and after stimulation, middle cerebral artery blood flow velocities also remained bilaterally unchanged, whereas vasomotor reactivity to CO(2) increased bilaterally (P = .04). The sham stimulation left all variables unchanged. The expected intermittent theta burst stimulation-induced changes in cortical excitability were not accompanied by changes in cerebral blood flow velocities; however, the bilateral increased vasomotor reactivity suggests that intermittent theta burst stimulation influences the cerebral microcirculation, possibly involving subcortical structures. These findings provide useful information on hemodynamic phenomena accompanying intermittent theta burst stimulation, which should be considered in research aimed at developing this noninvasive, low-intensity stimulation technique for safe

Minimally invasive direct coronary artery bypass versus off-pump coronary surgery through sternotomy

PubMed Central

Birla, R; Patel, P; Aresu, G

2013-01-01

Introduction Although it is not a new technique, minimally invasive direct coronary artery bypass (MIDCAB) is employed only by a few surgeons in the UK. We compared our experience with MIDCAB with that of single vessel off-pump coronary artery bypass (OPCAB) graft surgery through a standard median sternotomy. Methods Patients who underwent either MIDCAB or OPCAB between April 2008 and July 2011 were reviewed. Exclusion criteria included patients with an ejection fraction of <0.5 or previous cardiac surgery. Data were obtained retrospectively from our prospective database, medical records and through general practitioners. Results Overall, 74 patients were analysed in the MIDCAB group and 78 in the OPCAB group. Their demographics and EuroSCORE (European System for Cardiac Operative Risk Evaluation) values were comparable (p>0.05). There was no statistically significant difference in the two groups in terms of mortality, recurrent myocardial infarction, postoperative stroke, wound infection, atrial fibrillation or need for reintervention. The MIDCAB group had six conversions to a sternotomy. Eight patients in each group required blood transfusion, with the average transfusion being 1.8 units in the MIDCAB group and 3.2 units in the OPCAB group. The mean duration of ventilation and intensive care unit stay was 5.0 hours and 38.4 hours in the MIDCAB group and 5.4 and 47.8 hours in the OPCAB group. The mean hospital stay was significantly reduced in the MIDCAB population (6.1 vs 8.5 days, p<0.05). Conclusions MIDCAB can be performed safely in appropriately selected patients with outcomes comparable with OPCAB. The potential benefits include shorter hospital stay, reduced need for blood transfusion and faster recovery. PMID:24112493

4D motion modeling of the coronary arteries from CT images for robotic assisted minimally invasive surgery

NASA Astrophysics Data System (ADS)

Zhang, Dong Ping; Edwards, Eddie; Mei, Lin; Rueckert, Daniel

2009-02-01

In this paper, we present a novel approach for coronary artery motion modeling from cardiac Computed Tomography( CT) images. The aim of this work is to develop a 4D motion model of the coronaries for image guidance in robotic-assisted totally endoscopic coronary artery bypass (TECAB) surgery. To utilize the pre-operative cardiac images to guide the minimally invasive surgery, it is essential to have a 4D cardiac motion model to be registered with the stereo endoscopic images acquired intraoperatively using the da Vinci robotic system. In this paper, we are investigating the extraction of the coronary arteries and the modelling of their motion from a dynamic sequence of cardiac CT. We use a multi-scale vesselness filter to enhance vessels in the cardiac CT images. The centerlines of the arteries are extracted using a ridge traversal algorithm. Using this method the coronaries can be extracted in near real-time as only local information is used in vessel tracking. To compute the deformation of the coronaries due to cardiac motion, the motion is extracted from a dynamic sequence of cardiac CT. Each timeframe in this sequence is registered to the end-diastole timeframe of the sequence using a non-rigid registration algorithm based on free-form deformations. Once the images have been registered a dynamic motion model of the coronaries can be obtained by applying the computed free-form deformations to the extracted coronary arteries. To validate the accuracy of the motion model we compare the actual position of the coronaries in each time frame with the predicted position of the coronaries as estimated from the non-rigid registration. We expect that this motion model of coronaries can facilitate the planning of TECAB surgery, and through the registration with real-time endoscopic video images it can reduce the conversion rate from TECAB to conventional procedures.

The cost implications of an early versus delayed invasive strategy in Acute Coronary Syndromes: the TIMACS study.

PubMed

Bainey, Kevin R; Gafni, Amiram; Rao-Melacini, Purnima; Tong, Wesley; Steg, Philippe G; Faxon, David P; Lamy, Andre; Granger, Christopher B; Yusuf, Salim; Mehta, Shamir R

2014-06-01

The Timing of Intervention in Acute Coronary Syndromes (TIMACS) trial demonstrated that early invasive intervention (within 24 hours) was similar to a delayed approach (after 36 hours) overall but improved outcomes were seen in patients at high risk. However, the cost implications of an early versus delayed invasive strategy are unknown. A third-party perspective of direct cost was chosen and United States Medicare costs were calculated using average diagnosis related grouping (DRG) units. Direct medical costs included those of the index hospitalization (including clinical, procedural and hospital stay costs) as well as major adverse cardiac events during 6 months of follow-up. Sensitivity and sub-group analyses were performed. The average total cost per patient in the early intervention group was lower compared with the delayed intervention group (-$1170; 95% CI -$2542 to $202). From the bootstrap analysis (5000 replications), the early invasive approach was associated with both lower costs and better clinical outcomes regarding death/myocardial infarction (MI)/stroke in 95.1% of the cases (dominant strategy). In high-risk patients (GRACE score ≥141), the net reduction in cost was greatest (-$3720; 95% CI -$6270 to -$1170). Bootstrap analysis revealed 99.8% of cases were associated with both lower costs and better clinical outcomes (death/MI/stroke). We were unable to evaluate the effect of community care and investigations without hospitalization (office visits, non-invasive testing, etc). Medication costs were not captured. Indirect costs such as loss of productivity and family care were not included. An early invasive management strategy is as effective as a delayed approach and is likely to be less costly in most patients with acute coronary syndromes.

Vasomotor and Related Menopause Symptoms.

PubMed

Stuenkel, Cynthia A

2018-05-31

Vasomotor symptoms are the most common manifestation of the menopause transition and postmenopausal phases of reproductive life. They interfere not only in quality of life, but also contribute to sleep and mood disturbances that potentially compromise home and work effectiveness. Treatment options include hormone therapy (HT), nonhormonal prescription drugs, mind body and behavior therapies, and over-the-counter preparations. Evidence confirms that HT is the most effective option. The initial reticence to prescribe HT immediately following publication of the Women's Health Initiative has been replaced by clear guidelines for confidently identifying women for whom this therapy will be safe.

Short- and long-term black tea consumption reverses endothelial dysfunction in patients with coronary artery disease.

PubMed

Duffy, S J; Keaney , J F; Holbrook, M; Gokce, N; Swerdloff, P L; Frei, B; Vita, J A

2001-07-10

Epidemiological studies suggest that tea consumption decreases cardiovascular risk, but the mechanisms of benefit remain undefined. Endothelial dysfunction has been associated with coronary artery disease and increased oxidative stress. Some antioxidants have been shown to reverse endothelial dysfunction, and tea contains antioxidant flavonoids. Methods and Results-- To test the hypothesis that tea consumption will reverse endothelial dysfunction, we randomized 66 patients with proven coronary artery disease to consume black tea and water in a crossover design. Short-term effects were examined 2 hours after consumption of 450 mL tea or water. Long-term effects were examined after consumption of 900 mL tea or water daily for 4 weeks. Vasomotor function of the brachial artery was examined at baseline and after each intervention with vascular ultrasound. Fifty patients completed the protocol and had technically suitable ultrasound measurements. Both short- and long-term tea consumption improved endothelium- dependent flow-mediated dilation of the brachial artery, whereas consumption of water had no effect (P<0.001 by repeated-measures ANOVA). Tea consumption had no effect on endothelium-independent nitroglycerin-induced dilation. An equivalent oral dose of caffeine (200 mg) had no short-term effect on flow-mediated dilation. Plasma flavonoids increased after short- and long-term tea consumption. Short- and long-term black tea consumption reverses endothelial vasomotor dysfunction in patients with coronary artery disease. This finding may partly explain the association between tea intake and decreased cardiovascular disease events.

Nonpharmacologic, nonherbal management of menopause-associated vasomotor symptoms: an umbrella systematic review (protocol).

PubMed

Goldstein, Karen M; McDuffie, Jennifer R; Shepherd-Banigan, Megan; Befus, Deanna; Coeytaux, Remy R; Van Noord, Megan G; Goode, Adam P; Masilamani, Varsha; Adam, Soheir; Nagi, Avishek; Williams, John W

2016-04-07

Vasomotor symptoms such as hot flashes and night sweats are a common concern of perimenopausal and postmenopausal women and are associated with a decreased quality of life. These symptoms can be effectively managed with hormone therapy, but safety concerns limit its use. Thus, understanding the effectiveness of nonpharmacologic therapies such as acupuncture or yoga is critical to managing these common symptoms in older women. Our review seeks to address the following question: In women with menopause-associated vasomotor symptoms, what are the effects on health-related quality of life, vasomotor symptoms, and adverse events of the following nonpharmacologic, nonherbal interventions as compared with any inactive control or active comparator: (a) acupuncture, (b) yoga, tai chi, and qigong, (c) structured exercise, and (d) meditation, mindfulness-based practices, and relaxation? We describe a protocol for an umbrella review approach, supplemented by evaluating randomized controlled trials (RCTs) published after the most recent good-quality systematic review for each of the eligible interventions. Specific interventions were chosen based on current literature and with input from a technical expert panel and organizational stakeholders. We will conduct a thorough literature search and perform a quality assessment of potentially included systematic reviews and RCTs. Our umbrella review, supplemented by an additional search for eligible RCTs, aims to synthesize existing evidence on the use of nonpharmacologic, nonherbal interventions to manage bothersome vasomotor symptoms in perimenopausal and postmenopausal women. PROSPERO CRD42016029335.

Minimally invasive direct coronary artery bypass grafting: a meta-analysis.

PubMed

Kettering, K

2008-12-01

Recently minimally invasive direct coronary artery bypass (MIDCAB) grafting has become an interesting alternative to conventional coronary artery bypass grafting, especially in patients with a high-grade left anterior descending coronary artery (LAD) stenosis unsuitable for balloon angioplasty. Although MIDCAB offers several advantages such as the avoidance of sternotomy and cardiopulmonary bypass, concerns have been raised about the technical accuracy of the anastomoses that can be performed on a beating heart. Therefore, clinical and angiographic outcomes after MIDCAB are the subject of current controversy. A literature search for all published outcome studies of MIDCAB grafting was performed for the period from January 1995 through October 2007. Seventeen articles were enrolled in this meta-analysis. The data presented in the studies was analyzed with regard to clinical and angiographic results. Early and late (>30 days after MIDCAB) death rates were 1.3% (51/4081 patients) and 3.2% (130/4081 patients), respectively. The infarct rate was 0.8% (32/4081 patients; non-fatal myocardial infarction). Other minor or major complications (e.g. reoperation for management of bleeding, chest wound problems, arrhythmias, cerebrovascular accident, pericardial effusion, pulmonary complications) were reported in 781 cases. The conversion rate to sternotomy/cardiopulmonary bypass was 1.8% (74/4081 patients). A re-intervention due to graft failure was necessary in 134/4081 patients (3.3%). A total of 2556 grafts were studied angiographically immediately after surgery. One hundred and six grafts (4.2%) were occluded and 169 grafts (6.6 %) had a significant stenosis (50-99%). At 6-month follow-up, 445 grafts were studied angiographically. Sixteen grafts (3.6%) were occluded and 32 grafts (7.2%) had a significant stenosis. Clinical outcomes and immediate graft patency after MIDCAB are acceptable. However, long-term follow-up results and further randomized prospective clinical trials

Acupuncture for menopausal vasomotor symptoms: study protocol for a randomised controlled trial

PubMed Central

2014-01-01

Background Hot flushes and night sweats (vasomotor symptoms) are common menopausal symptoms, often causing distress, sleep deprivation and reduced quality of life. Although hormone replacement therapy is an effective treatment, there are concerns about serious adverse events. Non-hormonal pharmacological therapies are less effective and can also cause adverse effects. Complementary therapies, including acupuncture, are commonly used for menopausal vasomotor symptoms. While the evidence for the effectiveness of acupuncture in treating vasomotor symptoms is inconclusive, acupuncture has a low risk of adverse effects, and two small studies suggest it may be more effective than non-insertive sham acupuncture. Our objective is to assess the efficacy of needle acupuncture in improving hot flush severity and frequency in menopausal women. Our current study design is informed by methods tested in a pilot study. Methods/design This is a stratified, parallel, randomised sham-controlled trial with equal allocation of participants to two trial groups. We are recruiting 360 menopausal women experiencing a minimum average of seven moderate hot flushes a day over a seven-day period and who meet diagnostic criteria for the Traditional Chinese Medicine diagnosis of Kidney Yin deficiency. Exclusion criteria include breast cancer, surgical menopause, and current hormone replacement therapy use. Eligible women are randomised to receive either true needle acupuncture or sham acupuncture with non-insertive (blunt) needles for ten treatments over eight weeks. Participants are blinded to treatment allocation. Interventions are provided by Chinese medicine acupuncturists who have received specific training on trial procedures. The primary outcome measure is hot flush score, assessed using the validated Hot Flush Diary. Secondary outcome measures include health-related quality of life, anxiety and depression symptoms, credibility of the sham treatment, expectancy and beliefs about

Congenital Anomaly of Single Dominant Right Coronary Artery with Hypoplastic Left Coronary Artery.

PubMed

Chuang, Cheng-Yen; Chen, Yen-Chou; Cheng, Ho-Shun; Hsieh, Ming-Hsiung

2015-11-01

With the popularization of new imaging technology, more people are deciding to undergo non-invasive studies such as multidetector computerized tomography (MDCT) before receiving coronary angiography. For this reason, coronary anomalies of coronary artery are being encountered more frequently. We here report a 68-year-old male presenting with typical angina. The MDCT images suggested chronic total occlusion of the left anterior descending (LAD) artery with collateral circulation from the right coronary artery (RCA). The patient's coronary angiography showed a congenital coronary anomaly with a single dominant RCA supplying the entire coronary circulation of the heart with both LAD and left circumflex artery hypoplasia. Angiography; Anomaly; Computerized tomography; Coronary artery.

Stable coronary syndromes: pathophysiology, diagnostic advances and therapeutic need

PubMed Central

Corcoran, David

2018-01-01

The diagnostic management of patients with angina pectoris typically centres on the detection of obstructive epicardial CAD, which aligns with evidence-based treatment options that include medical therapy and myocardial revascularisation. This clinical paradigm fails to account for the considerable proportion (approximately one-third) of patients with angina in whom obstructive CAD is excluded. This common scenario presents a diagnostic conundrum whereby angina occurs but there is no obstructive CAD (ischaemia and no obstructive coronary artery disease—INOCA). We review new insights into the pathophysiology of angina whereby myocardial ischaemia results from a deficient supply of oxygenated blood to the myocardium, due to various combinations of focal or diffuse epicardial disease (macrovascular), microvascular dysfunction or both. Macrovascular disease may be due to the presence of obstructive CAD secondary to atherosclerosis, or may be dynamic due to a functional disorder (eg, coronary artery spasm, myocardial bridging). Pathophysiology of coronary microvascular disease may involve anatomical abnormalities resulting in increased coronary resistance, or functional abnormalities resulting in abnormal vasomotor tone. We consider novel clinical diagnostic techniques enabling new insights into the causes of angina and appraise the need for improved therapeutic options for patients with INOCA. We conclude that the taxonomy of stable CAD could improve to better reflect the heterogeneous pathophysiology of the coronary circulation. We propose the term ‘stable coronary syndromes’ (SCS), which aligns with the well-established terminology for ‘acute coronary syndromes’. SCS subtends a clinically relevant classification that more fully encompasses the different diseases of the epicardial and microvascular coronary circulation. PMID:29030424

Percutaneous transluminal coronary angioplasty (PTCA)

MedlinePlus Videos and Cool Tools

... angioplasty (PTCA) is a minimally invasive procedure to open up blocked coronary arteries, allowing blood to circulate ... within the coronary artery to keep the vessel open. Once the compression has been performed, contrast media ...

Vasomotor Symptoms Monitoring with a Commercial Activity Tracking Watch

DTIC Science & Technology

2017-12-31

volunteers wearing physiological monitors. The study protocol and written consent form were...available, but similar devices with EDA/GSR sensors are available. Vasomotor symptoms started disrupting the sleep of a woman volunteer on...November 23, 2015, calling attention to their occurrence. After November 23, 2015, the volunteer started personally logging the occurrence of

Use of Coronary Computed Tomographic Angiography to Guide Management of Patients With Coronary Disease

PubMed Central

Williams, Michelle C.; Hunter, Amanda; Shah, Anoop S.V.; Assi, Valentina; Lewis, Stephanie; Smith, Joel; Berry, Colin; Boon, Nicholas A.; Clark, Elizabeth; Flather, Marcus; Forbes, John; McLean, Scott; Roditi, Giles; van Beek, Edwin J.R.; Timmis, Adam D.; Newby, David E.

2016-01-01

Background In a prospective, multicenter, randomized controlled trial, 4,146 patients were randomized to receive standard care or standard care plus coronary computed tomography angiography (CCTA). Objectives The purpose of this study was to explore the consequences of CCTA-assisted diagnosis on invasive coronary angiography, preventive treatments, and clinical outcomes. Methods In post hoc analyses, we assessed changes in invasive coronary angiography, preventive treatments, and clinical outcomes using national electronic health records. Results Despite similar overall rates (409 vs. 401; p = 0.451), invasive angiography was less likely to demonstrate normal coronary arteries (20 vs. 56; hazard ratios [HRs]: 0.39 [95% confidence interval (CI): 0.23 to 0.68]; p < 0.001) but more likely to show obstructive coronary artery disease (283 vs. 230; HR: 1.29 [95% CI: 1.08 to 1.55]; p = 0.005) in those allocated to CCTA. More preventive therapies (283 vs. 74; HR: 4.03 [95% CI: 3.12 to 5.20]; p < 0.001) were initiated after CCTA, with each drug commencing at a median of 48 to 52 days after clinic attendance. From the median time for preventive therapy initiation (50 days), fatal and nonfatal myocardial infarction was halved in patients allocated to CCTA compared with those assigned to standard care (17 vs. 34; HR: 0.50 [95% CI: 0.28 to 0.88]; p = 0.020). Cumulative 6-month costs were slightly higher with CCTA: difference $462 (95% CI: $303 to $621). Conclusions In patients with suspected angina due to coronary heart disease, CCTA leads to more appropriate use of invasive angiography and alterations in preventive therapies that were associated with a halving of fatal and non-fatal myocardial infarction. (Scottish COmputed Tomography of the HEART Trial [SCOT-HEART]; NCT01149590) PMID:27081014

Bioresorbable scaffolds for percutaneous coronary interventions

PubMed Central

Gogas, Bill D.

2014-01-01

Innovations in drug-eluting stents (DES) have substantially reduced rates of in-segment restenosis and early stent thrombosis, improving clinical outcomes following percutaneous coronary interventions (PCI). However a fixed metallic implant in a vessel wall with restored patency and residual disease remains a precipitating factor for sustained local inflammation, in-stent neo-atherosclerosis and impaired vasomotor function increasing the risk for late complications attributed to late or very late stent thrombosis and late target lesion revascularization (TLR) (late catch-up). The quest for optimal coronary stenting continues by further innovations in stent design and by using biocompatible materials other than cobalt chromium, platinum chromium or stainless steel for engineering coronary implants. Bioresorbable scaffolds made of biodegradable polymers or biocorrodible metals with properties of transient vessel scaffolding, local drug-elution and future restoration of vessel anatomy, physiology and local hemodynamics have been recently developed. These devices have been utilized in selected clinical applications so far providing preliminary evidence of safety showing comparable performance with current generation drug-eluting stents (DES). Herein we provide a comprehensive overview of the current status of these technologies, we elaborate on the potential benefits of transient coronary scaffolds over permanent stents in the context of vascular reparation therapy, and we further focus on the evolving challenges these devices have to overcome to compete with current generation DES. Condensed Abstract:: The quest for optimizing percutaneous coronary interventions continues by iterative innovations in device materials beyond cobalt chromium, platinum chromium or stainless steel for engineering coronary implants. Bioresorbable scaffolds made of biodegradable polymers or biocorrodible metals with properties of transient vessel scaffolding; local drug-elution and future

64 slice-coronary computed tomography sensitivity and specificity in the evaluation of coronary artery bypass graft stenosis: A meta-analysis.

PubMed

Barbero, Umberto; Iannaccone, Mario; d'Ascenzo, Fabrizio; Barbero, Cristina; Mohamed, Abdirashid; Annone, Umberto; Benedetto, Sara; Celentani, Dario; Gagliardi, Marco; Moretti, Claudio; Gaita, Fiorenzo

2016-08-01

A non-invasive approach to define grafts patency and stenosis in the follow-up of coronary artery bypass graft (CABG) patients may be an interesting alternative to coronary angiography. 64-slice-coronary computed tomography is nowadays a diffused non-invasive method that permits an accurate evaluation of coronary stenosis, due to a high temporal and spatial resolution. However, its sensitivity and specificity in CABG evaluation has to be clearly defined, since published studies used different protocols and scanners. We collected all studies investigating patients with stable symptoms and previous CABG and reporting the comparison between diagnostic performances of invasive coronary angiography and 64-slice-coronary computed tomography. As a result, sensitivity and specificity of 64-slice-coronary computed tomography for CABG occlusion were 0.99 (95% CI 0.97-1.00) and 0.99 (95% CI: 0.99-1.00) with an area under the curve (AUC) of 0.99. 64-slice-coronary computed tomography sensitivity and specificity for the presence of any CABG stenosis >50% were 0.98 (95% CI: 0.97-0.99) and 0.98 (95% CI: 0.96-0.98), while AUC was 0.99. At meta-regression, neither the age nor the time from graft implantation had effect on sensitivity and specificity of 64-slice-coronary computed tomography detection of significant CABG stenosis or occlusion. In conclusion 64-slice-coronary computed tomography confirmed its high sensitivity and specificity in CABG stenosis or occlusion evaluation. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Reduced Incidence of Invasive Breast Cancer With Raloxifene Among Women at Increased Coronary Risk

PubMed Central

Grady, Deborah; Cauley, Jane A.; Geiger, Mary Jane; Kornitzer, Marcel; Mosca, Lori; Collins, Peter; Wenger, Nanette K.; Song, Jingli; Mershon, John; Barrett-Connor, Elizabeth

2013-01-01

Background In the Raloxifene Use for The Heart trial, 10 101 postmenopausal women with coronary heart disease (CHD) or multiple CHD risk factors were randomly assigned to 60 mg/d raloxifene or to placebo and followed for a median of 5.6 years. Raloxifene, a selective estrogen receptor modulator, was found to reduce the risk of invasive breast cancer and vertebral fractures but not the risk of cardiovascular events. Here, we provide further details about breast cancer incidence by tumor characteristics, duration of treatment, and subgroup. Methods Reported breast cancer was adjudicated by an independent committee based on medical records and pathology reports. The primary analyses used Cox proportional hazards models with time to first breast cancer as the outcome. Subgroup effects were analyzed using similar models with terms for treatment by subgroup. All statistical tests were two-sided. Results As previously reported, raloxifene reduced the incidence of invasive breast cancer by 44% (hazard ratio [HR] = 0.56; 95% confidence interval [CI] = 0.38 to 0.83; absolute risk reduction = 1.2 invasive breast cancers per 1000 women treated for 1 year). The lower incidence of invasive breast cancer reflected a 55% lower incidence of invasive estrogen receptor (ER)–positive tumors (HR = 0.45; 95% CI = 0.28 to 0.72). However, raloxifene treatment did not reduce the incidence of noninvasive breast cancer or of invasive ER-negative breast cancer. The reduced incidence of invasive breast cancer was similar across subgroups, including those defined by age, body mass index, family history of breast cancer, prior use of postmenopausal hormones, and 5-year estimated risk of invasive breast cancer. Conclusion Raloxifene reduces risk of invasive ER-positive breast cancer regardless of a woman's baseline breast cancer risk but does not reduce risk of noninvasive or ER-negative breast cancers. These results confirm those of the Multiple Outcomes of Raloxifene Evaluation, a previous

Shaker-related voltage-gated K+ channel expression and vasomotor function in human coronary resistance arteries.

PubMed

Nishijima, Yoshinori; Korishettar, Ankush; Chabowski, Dawid S; Cao, Sheng; Zheng, Xiaodong; Gutterman, David D; Zhang, David X

2018-01-01

K V channels are important regulators of vascular tone, but the identity of specific K V channels involved and their regulation in disease remain less well understood. We determined the expression of K V 1 channel subunits and their role in cAMP-mediated dilation in coronary resistance arteries from subjects with and without CAD. HCAs from patients with and without CAD were assessed for mRNA and protein expression of K V 1 channel subunits with molecular techniques and for vasodilator response with isolated arterial myography. Assays of mRNA transcripts, membrane protein expression, and vascular cell-specific localization revealed abundant expression of K V 1.5 in vascular smooth muscle cells of non-CAD HCAs. Isoproterenol and forskolin, two distinct cAMP-mediated vasodilators, induced potent dilation of non-CAD arterioles, which was inhibited by both the general K V blocker 4-AP and the selective K V 1.5 blocker DPO-1. The cAMP-mediated dilation was reduced in CAD and was accompanied by a loss of or reduced contribution of 4-AP-sensitive K V channels. K V 1.5, as a major 4-AP-sensitive K V 1 channel expressed in coronary VSMCs, mediates cAMP-mediated dilation in non-CAD arterioles. The cAMP-mediated dilation is reduced in CAD coronary arterioles, which is associated with impaired 4-AP-sensitive K V channel function. © 2017 John Wiley & Sons Ltd.

Safety and Efficacy of Black Cohosh and Red Clover for the Management of Vasomotor Symptoms: A Randomized Controlled Trial

PubMed Central

Geller, Stacie E.; Shulman, Lee P.; van Breemen, Richard B.; Banuvar, Suzanne; Zhou, Ying; Epstein, Geena; Hedayat, Samad; Nikolic, Dejan; Krause, Elizabeth C.; Piersen, Colleen E.; Bolton, Judy L.; Pauli, Guido F.; Farnsworth, Norman R.

2009-01-01

Objective The aim of this study was to evaluate the safety and efficacy of black cohosh and red clover compared with placebo for the relief of menopausal vasomotor symptoms. Design This study was a randomized, four-arm, double-blind clinical trial of standardized black cohosh, red clover, placebo and 0.625 mg conjugated equine estrogens plus 2.5 mg medroxyprogesterone acetate (CEE/MPA; n = 89). Primary outcome measures were reduction in vasomotor symptoms (hot flashes and night sweats) by black cohosh and red clover compared with placebo; secondary outcomes included safety evaluation, reduction of somatic symptoms, relief of sexual dysfunction, and overall improvement in quality of life. Results Reductions in number of vasomotor symptoms after 12-month intervention were as follows: black cohosh (34%), red clover (57%), placebo (63%), and CEE/MPA (94%), with only CEE/MPA differing significantly from placebo. Black cohosh and red clover did not significantly reduce the frequency of vasomotor symptoms as compared with placebo. Secondary measures indicated that both botanicals were safe as administered. In general, there were no improvements in other menopausal symptoms. Conclusions Compared with placebo, black cohosh and red clover did not reduce the number of vasomotor symptoms. Safety monitoring indicated that chemically and biologically standardized extracts of black cohosh and red clover were safe during daily administration for 12 months. PMID:19609225

Patient-specific coronary territory maps

NASA Astrophysics Data System (ADS)

Beliveau, Pascale; Setser, Randolph; Cheriet, Farida; O'Donnell, Thomas

2007-03-01

It is standard practice for physicians to rely on empirical, population based models to define the relationship between regions of left ventricular (LV) myocardium and the coronary arteries which supply them with blood. Physicians use these models to infer the presence and location of disease within the coronary arteries based on the condition of the myocardium within their distribution (which can be established non-invasively using imaging techniques such as ultrasound or magnetic resonance imaging). However, coronary artery anatomy often varies from the assumed model distribution in the individual patient; thus, a non-invasive method to determine the correspondence between coronary artery anatomy and LV myocardium would have immediate clinical impact. This paper introduces an image-based rendering technique for visualizing maps of coronary distribution in a patient-specific approach. From an image volume derived from computed tomography (CT) images, a segmentation of the LV epicardial surface, as well as the paths of the coronary arteries, is obtained. These paths form seed points for a competitive region growing algorithm applied to the surface of the LV. A ray casting procedure in spherical coordinates from the center of the LV is then performed. The cast rays are mapped to a two-dimensional circular based surface forming our coronary distribution map. We applied our technique to a patient with known coronary artery disease and a qualitative evaluation by an expert in coronary cardiac anatomy showed promising results.

Evaluation of computed tomography in patients with atypical angina or chest pain clinically referred for invasive coronary angiography: randomised controlled trial

PubMed Central

Rief, Matthias; Martus, Peter; Kendziora, Benjamin; Feger, Sarah; Dreger, Henryk; Priem, Sascha; Knebel, Fabian; Böhm, Marko; Schlattmann, Peter; Hamm, Bernd; Schönenberger, Eva; Laule, Michael; Zimmermann, Elke

2016-01-01

Objective To evaluate whether invasive coronary angiography or computed tomography (CT) should be performed in patients clinically referred for coronary angiography with an intermediate probability of coronary artery disease. Design Prospective randomised single centre trial. Setting University hospital in Germany. Participants 340 patients with suspected coronary artery disease and a clinical indication for coronary angiography on the basis of atypical angina or chest pain. Interventions 168 patients were randomised to CT and 172 to coronary angiography. After randomisation one patient declined CT and 10 patients declined coronary angiography, leaving 167 patients (88 women) and 162 patients (78 women) for analysis. Allocation could not be blinded, but blinded independent investigators assessed outcomes. Main outcome measure The primary outcome measure was major procedural complications within 48 hours of the last procedure related to CT or angiography. Results Cardiac CT reduced the need for coronary angiography from 100% to 14% (95% confidence interval 9% to 20%, P<0.001) and was associated with a significantly greater diagnostic yield from coronary angiography: 75% (53% to 90%) v 15% (10% to 22%), P<0.001. Major procedural complications were uncommon (0.3%) and similar across groups. Minor procedural complications were less common in the CT group than in the coronary angiography group: 3.6% (1% to 8%) v 10.5% (6% to 16%), P=0.014. CT shortened the median length of stay in the angiography group from 52.9 hours (interquartile range 49.5-76.4 hours) to 30.0 hours (3.5-77.3 hours, P<0.001). Overall median exposure to radiation was similar between the CT and angiography groups: 5.0 mSv (interquartile range 4.2-8.7 mSv) v 6.4 mSv (3.4-10.7 mSv), P=0.45. After a median follow-up of 3.3 years, major adverse cardiovascular events had occurred in seven of 167 patients in the CT group (4.2%) and six of 162 (3.7%) in the coronary angiography group (adjusted hazard

Cocaine and coronary calcification in young adults: the Coronary Artery Risk Development in Young Adults (CARDIA) Study.

PubMed

Pletcher, Mark J; Kiefe, Catarina I; Sidney, Steve; Carr, J Jeffrey; Lewis, Cora E; Hulley, Stephen B

2005-11-01

Cocaine use is associated with myocardial ischemia and infarction, but it is unclear whether this is only because of the acute effects of cocaine on heart rate, blood pressure, and vasomotor tone or whether accelerated atherosclerosis from long-term exposure to cocaine also contributes. We sought to measure the association between cocaine exposure and coronary calcification, a marker for atherosclerosis, among participants in the CARDIA Study who received computed tomography scanning and answered questions about illicit drug use at the year 15 examination in 2000-2001. Among 3038 CARDIA participants (age 33-45 years, 55% women and 45% black), past cocaine exposure was reported by 35% and was more common among men, smokers, drinkers, and participants with less education. Powdered cocaine exposure was more common among whites, crack cocaine among blacks. Before adjustment, cocaine exposure was strongly associated with coronary calcification. After adjusting for age, sex, ethnicity, socioeconomic status, family history, and habits, however, these associations disappeared: adjusted odds ratios for coronary calcification were 0.9 (95% CI 0.6-1.3) for 1 to 10, 1.2 (95% CI 0.8-1.7) for 11 to 99, and 1.0 (95% CI 0.6-1.6) for > or =100 lifetime episodes of cocaine use, in comparison with none. Sex, tobacco, and alcohol use appeared to be primarily responsible for the confounding we observed in unadjusted models. We found no evidence of a causal relationship between long-term exposure to cocaine and coronary calcification and conclude that acute nonatherogenic mechanisms probably explain most cocaine-associated myocardial infarction.

Less invasive coronary artery revascularization with a minimized extracorporeal circulation system: preliminary results of a comparative study with off-pump-procedures

PubMed Central

2013-01-01

Background Coronary-artery-bypass-grafting (CABG) with conventional extracorporeal circulation (CECC) is associated with adverse effects such as systemic inflammatory response leading to a decrease in systemic vascular resistance and hemodynamic instability. Modern "less invasive" procedures have been established recently which potentially avoid negative side effects of CECC. The aim of this study was to compare perioperative outcome following coronary revascularization using either a minimized extracorporeal circuit (Mini-HLM) or off-pump technique (OPCAB). Methods In this prospective ethics-approved trial, 120 patients referred for CABG were randomly assigned either to off-pump coronary artery bypass (OPCAB) or to a Mini-HLM procedure. Patient demographics, preoperative characteristics and extensive postoperative outcome were analyzed for both groups. Hemodynamic data were measured at seven time points perioperatively. Results Operation-time was longer in the Mini-HLM group (178,3 ± 32,9 min) compared to OPCAB (133,2 ± 32,7 min, p < 0,001) with higher graft numbers in Mini-HLM group (3,11 ± 0,7 vs. 1,78 ± 0,7, p < 0.001). There were no significant differences in perioperative hemodynamic criteria, catecholaminergic support, hospital (p = 0,534) and intensive care unit stay (p = 0,880), ventilation time (p = 0,113), blood loss (p = 0,570), transfusion requirements, postoperative atrial fibrillation rate (p = 0,706) and neurocognitive disturbance (p = 0,297). No deaths and no myocardial infarctions were observed. Conclusions Coronary revascularisation with Mini-HLM represents a suitable and "less invasive" procedure which achieves all benefits of OPCAB but may allow for less demanding revascularisation than OPCAB in special patients with complex coronary anatomy and can therefore be used both on a routine basis and in all "conversion" cases of OPCAB. PMID:23577663

Methods for the design of vasomotor symptom trials: the menopausal strategies: finding lasting answers to symptoms and health network.

PubMed

Newton, Katherine M; Carpenter, Janet S; Guthrie, Katherine A; Anderson, Garnet L; Caan, Bette; Cohen, Lee S; Ensrud, Kristine E; Freeman, Ellen W; Joffe, Hadine; Sternfeld, Barbara; Reed, Susan D; Sherman, Sheryl; Sammel, Mary D; Kroenke, Kurt; Larson, Joseph C; Lacroix, Andrea Z

2014-01-01

This report describes the Menopausal Strategies: Finding Lasting Answers to Symptoms and Health network and methodological issues addressed in designing and implementing vasomotor symptom trials. Established in response to a National Institutes of Health request for applications, the network was charged with conducting rapid throughput randomized trials of novel and understudied available interventions postulated to alleviate vasomotor and other menopausal symptoms. Included are descriptions of and rationale for criteria used for interventions and study selection, common eligibility and exclusion criteria, common primary and secondary outcome measures, consideration of placebo response, establishment of a biorepository, trial duration, screening and recruitment, statistical methods, and quality control. All trial designs are presented, including the following: (1) a randomized, double-blind, placebo-controlled clinical trial designed to evaluate the effectiveness of the selective serotonin reuptake inhibitor escitalopram in reducing vasomotor symptom frequency and severity; (2) a two-by-three factorial design trial to test three different interventions (yoga, exercise, and ω-3 supplementation) for the improvement of vasomotor symptom frequency and bother; and (3) a three-arm comparative efficacy trial of the serotonin-norepinephrine reuptake inhibitor venlafaxine and low-dose oral estradiol versus placebo for reducing vasomotor symptom frequency. The network's structure and governance are also discussed. The methods used in and the lessons learned from the Menopausal Strategies: Finding Lasting Answers to Symptoms and Health trials are shared to encourage and support the conduct of similar trials and to encourage collaborations with other researchers.

Early versus delayed invasive strategy for intermediate- and high-risk acute coronary syndromes managed without P2Y12 receptor inhibitor pretreatment: Design and rationale of the EARLY randomized trial.

PubMed

Lemesle, Gilles; Laine, Marc; Pankert, Mathieu; Puymirat, Etienne; Cuisset, Thomas; Boueri, Ziad; Maillard, Luc; Armero, Sébastien; Cayla, Guillaume; Bali, Laurent; Motreff, Pascal; Peyre, Jean-Pascal; Paganelli, Franck; Kerbaul, François; Roch, Antoine; Michelet, Pierre; Baumstarck, Karine; Bonello, Laurent

2018-01-01

According to recent literature, pretreatment with a P2Y 12 ADP receptor antagonist before coronary angiography appears no longer suitable in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) due to an unfavorable risk-benefit ratio. Optimal delay of the invasive strategy in this specific context is unknown. We hypothesize that without P2Y 12 ADP receptor antagonist pretreatment, a very early invasive strategy may be beneficial. The EARLY trial (Early or Delayed Revascularization for Intermediate- and High-Risk Non-ST-Segment Elevation Acute Coronary Syndromes?) is a prospective, multicenter, randomized, controlled, open-label, 2-parallel-group study that plans to enroll 740 patients. Patients are eligible if the diagnosis of intermediate- or high-risk NSTE-ACS is made and an invasive strategy intended. Patients are randomized in a 1:1 ratio. In the control group, a delayed strategy is adopted, with the coronary angiography taking place between 12 and 72 hours after randomization. In the experimental group, a very early invasive strategy is performed within 2 hours. A loading dose of a P2Y 12 ADP receptor antagonist is given at the time of intervention in both groups. Recruitment began in September 2016 (n = 558 patients as of October 2017). The primary endpoint is the composite of cardiovascular death and recurrent ischemic events at 1 month. The EARLY trial aims to demonstrate the superiority of a very early invasive strategy compared with a delayed strategy in intermediate- and high-risk NSTE-ACS patients managed without P2Y 12 ADP receptor antagonist pretreatment. © 2018 Wiley Periodicals, Inc.

Vegans report less bothersome vasomotor and physical menopausal symptoms than omnivores.

PubMed

Beezhold, Bonnie; Radnitz, Cynthia; McGrath, Robert E; Feldman, Arielle

2018-06-01

Lifestyle modifications that may reduce menopausal symptoms have generated much interest. The vegetarian diet has been associated with a lower risk of chronic disease as well as a more healthy hormonal milieu. Our objective in this cross-sectional study was to survey peri- and postmenopausal women to investigate menopausal symptoms and dietary pattern. Survey distribution in 2015-2016 was aimed at female vegans, vegetarians, and omnivores between the ages of 45 and 80 years, who were active on senior and vegetarian social networking websites and at vegan restaurants and events. We investigated vasomotor and physical symptoms as measured by the Menopause-specific Quality of Life Questionnaire (MENQOL) and dietary pattern classified by animal protein intakes reported in response to food frequency questions. Out of 754 participants who completed the survey, 604 reported they were perimenopausal (n = 121) or postmenopausal (n = 483), of whom 539 also completed the food frequency questions. We compared vasomotor and physical symptoms in omnivores (n = 304, consumed meat and/or poultry at least monthly) and vegans (n = 125, abstained from all animal proteins) using general linear models; covariates included age, exercise, hormone replacement therapy, presence of reproductive organs, and age at menopause. Among perimenopausal women, vegans reported less bothersome vasomotor (p < 0.01) and physical symptoms (p < 0.01) than omnivores. For both symptom types, more vegetables and less flesh food were associated with less bothersome symptoms (p values < 0.05). Eating a plant-based diet may be helpful for women in menopausal transition who prefer a natural means to manage their symptoms. Copyright © 2018 Elsevier B.V. All rights reserved.

Timing of angiography with a routine invasive strategy and long-term outcomes in non-ST-segment elevation acute coronary syndrome: a collaborative analysis of individual patient data from the FRISC II (Fragmin and Fast Revascularization During Instability in Coronary Artery Disease), ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes), and RITA-3 (Intervention Versus Conservative Treatment Strategy in Patients With Unstable Angina or Non-ST Elevation Myocardial Infarction) Trials.

PubMed

Damman, Peter; van Geloven, Nan; Wallentin, Lars; Lagerqvist, Bo; Fox, Keith A A; Clayton, Tim; Pocock, Stuart J; Hirsch, Alexander; Windhausen, Fons; Tijssen, Jan G P; de Winter, Robbert J

2012-02-01

This study sought to investigate long-term outcomes after early or delayed angiography in patients with non-ST-segment elevation acute coronary syndrome (nSTE-ACS) undergoing a routine invasive management. The optimal timing of angiography in patients with nSTE-ACS is currently a topic for debate. Long-term follow-up after early (within 2 days) angiography versus delayed (within 3 to 5 days) angiography was investigated in the FRISC-II (Fragmin and Fast Revascularization During Instability in Coronary Artery Disease), ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes), and RITA-3 (Intervention Versus Conservative Treatment Strategy in Patients With Unstable Angina or Non-ST Elevation Myocardial Infarction) (FIR) nSTE-ACS patient-pooled database. The main outcome was cardiovascular death or myocardial infarction up to 5-year follow-up. Hazard ratios (HR) were calculated with Cox regression models. Adjustments were made for the FIR risk score, study, and the propensity of receiving early angiography using inverse probability weighting. Of 2,721 patients originally randomized to the routine invasive arm, consisting of routine angiography and subsequent revascularization if suitable, 975 underwent early angiography and 1,141 delayed angiography. No difference was observed in 5-year cardiovascular death or myocardial infarction in unadjusted (HR: 1.06, 95% confidence interval [CI]: 0.79 to 1.42, p=0.61) and adjusted (HR: 0.93, 95% CI: 0.75 to 1.16, p=0.54) Cox regression models. In the FIR database of patients presenting with nSTE-ACS, the timing of angiography was not related to long-term cardiovascular mortality or myocardial infarction. (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes [ICTUS]; ISRCTN82153174. Intervention Versus Conservative Treatment Strategy in Patients With Unstable Angina or Non-ST Elevation Myocardial Infarction [the Third Randomised Intervention Treatment of Angina Trials (RITA-3)]; ISRCTN

Evaluation of computed tomography in patients with atypical angina or chest pain clinically referred for invasive coronary angiography: randomised controlled trial.

PubMed

Dewey, Marc; Rief, Matthias; Martus, Peter; Kendziora, Benjamin; Feger, Sarah; Dreger, Henryk; Priem, Sascha; Knebel, Fabian; Böhm, Marko; Schlattmann, Peter; Hamm, Bernd; Schönenberger, Eva; Laule, Michael; Zimmermann, Elke

2016-10-24

 To evaluate whether invasive coronary angiography or computed tomography (CT) should be performed in patients clinically referred for coronary angiography with an intermediate probability of coronary artery disease.  Prospective randomised single centre trial.  University hospital in Germany.  340 patients with suspected coronary artery disease and a clinical indication for coronary angiography on the basis of atypical angina or chest pain.  168 patients were randomised to CT and 172 to coronary angiography. After randomisation one patient declined CT and 10 patients declined coronary angiography, leaving 167 patients (88 women) and 162 patients (78 women) for analysis. Allocation could not be blinded, but blinded independent investigators assessed outcomes.  The primary outcome measure was major procedural complications within 48 hours of the last procedure related to CT or angiography.  Cardiac CT reduced the need for coronary angiography from 100% to 14% (95% confidence interval 9% to 20%, P<0.001) and was associated with a significantly greater diagnostic yield from coronary angiography: 75% (53% to 90%) v 15% (10% to 22%), P<0.001. Major procedural complications were uncommon (0.3%) and similar across groups. Minor procedural complications were less common in the CT group than in the coronary angiography group: 3.6% (1% to 8%) v 10.5% (6% to 16%), P=0.014. CT shortened the median length of stay in the angiography group from 52.9 hours (interquartile range 49.5-76.4 hours) to 30.0 hours (3.5-77.3 hours, P<0.001). Overall median exposure to radiation was similar between the CT and angiography groups: 5.0 mSv (interquartile range 4.2-8.7 mSv) v 6.4 mSv (3.4-10.7 mSv), P=0.45. After a median follow-up of 3.3 years, major adverse cardiovascular events had occurred in seven of 167 patients in the CT group (4.2%) and six of 162 (3.7%) in the coronary angiography group (adjusted hazard ratio 0.90, 95% confidence interval 0.30 to 2.69, P=0.86). 79% of patients

Regional Coronary Endothelial Function is Closely Related to Local Early Coronary Atherosclerosis in Patients with Mild Coronary Artery Disease: A Pilot Study

PubMed Central

Hays, Allison G.; Kelle, Sebastian; Hirsch, Glenn A.; Soleimanifard, Sahar; Yu, Jing; Agarwal, Harsh K.; Gerstenblith, Gary; Schär, Michael; Stuber, Matthias; Weiss, Robert G.

2012-01-01

Background Coronary endothelial function (endoFx) is abnormal in patients with established coronary artery disease (CAD) and was recently shown by MRI to relate to the severity of luminal stenosis. Recent advances in MRI now allow the non-invasive assessment of both anatomic and functional (endoFx) changes that previously required invasive studies. We tested the hypothesis that abnormal coronary endoFx is related to measures of early atherosclerosis such as increased coronary wall thickness (CWT). Methods and Results Seventeen arteries in fourteen healthy adults and seventeen arteries in fourteen patients with non-obstructive CAD were studied. To measure endoFx, coronary MRI was performed before and during isometric handgrip exercise, an endothelial-dependent stressor and changes in coronary cross-sectional area (CSA) and flow were measured. Black blood imaging was performed to quantify CWT and other indices of arterial remodeling. The mean stress-induced change in CSA was significantly higher in healthy adults (13.5%±12.8%, mean±SD, n=17) than in those with mildly diseased arteries (-2.2±6.8%, p<0.0001, n=17). Mean CWT was lower in healthy subjects (0.9±0.2mm) than in CAD patients (1.4±0.3mm, p<0.0001). In contrast to healthy subjects, stress-induced changes in CSA, a measure of coronary endoFx, correlated inversely with CWT in CAD patients (r= -0.73, p=0.0008). Conclusions There is an inverse relationship between coronary endothelial function and local CWT in CAD patients but not in healthy adults. These findings demonstrate that local endothelial-dependent functional changes are related to the extent of early anatomic atherosclerosis in mildly diseased arteries. This combined MRI approach enables the anatomic and functional investigation of early coronary disease. PMID:22492483

Alternative complement pathway activation during invasive coronary procedures in acute myocardial infarction and stable angina pectoris.

PubMed

Horváth, Zsófia; Csuka, Dorottya; Vargova, Katarina; Kovács, Andrea; Leé, Sarolta; Varga, Lilian; Préda, István; Tóth Zsámboki, Emese; Prohászka, Zoltán; Kiss, Róbert Gábor

2016-12-01

The effect of invasive percutaneous coronary procedures on complement activation has not been elucidated. We enrolled stable angina patients with elective percutaneous coronary intervention (SA-PCI, n=24), diagnostic coronary angiography (CA, n=52) and 23 patients with ST segment elevation myocardial infarction and primary PCI (STEMI-PCI). Complement activation products (C1rC1sC1inh, C3bBbP and SC5b-9) were measured on admission, 6 and 24h after coronary procedures. The alternative pathway product, C3bBbP significantly and reversibly increased 6h after elective PCI (baseline: 7.81AU/ml, 6h: 16.09AU/ml, 24h: 4.27AU/ml, p<0.01, n=23) and diagnostic angiography (baseline: 6.13AU/ml, 6h: 12.08AU/ml, 24h: 5.4AU/ml, p<0.01, n=52). Six hour C3bBbP values correlated with post-procedural CK, creatinine level and the applied contrast material volume (r=0.41, r=0.4, r=0.3, p<0.05, respectively). In STEMI-PCI, baseline C3bBbP level was higher, compared to SA-PCI or CA patients (11.33AU/ml vs. 7.81AU/ml or 6.13AU/ml, p<0.001). Similarly, the terminal complex (SC5b-9) level was already elevated at baseline compared to SA-PCI group (3.49AU/ml vs. 1.87AU/ml, p=0.011). Complement pathway products did not increase further after primary PCI. Elective coronary procedures induced transient alternative complement pathway activation, influenced by the applied contrast volume. In STEMI, the alternative complement pathway is promptly activated during the atherothrombotic event and PCI itself had no further detectable effect. Copyright © 2016 Elsevier B.V. All rights reserved.

Preinfarct Health Status and the Use of Early Invasive Versus Ischemia-Guided Management in Non-ST-Elevation Acute Coronary Syndrome.

PubMed

Qintar, Mohammed; Smolderen, Kim G; Chan, Paul S; Gosch, Kensey L; Jones, Philip G; Buchanan, Donna M; Girotra, Saket; Spertus, John A

2017-10-01

Early invasive management improves outcomes in non-ST-elevation myocardial infarction (NSTEMI). The association between preinfarct health status and the selecting patients for early invasive management is unknown. The Prospective Registry Evaluating outcomes after Myocardial Infarctions: Events and Recovery and Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients' Health status are consecutive US multicenter registries, in which the associations between preinfarct angina frequency and quality of life (both assessed by the Seattle Angina Questionnaire on admission) and the Global Registry of Acute Coronary Events (GRACE) risk score and referral to early invasive management (coronary angiography within 48 hours) were evaluated using Poisson regression, after adjusting for site, demographics, and clinical and psychosocial variables. Of 3,768 patients with NSTEMI, 2,182 (57.9%) patients were referred for early invasive treatment. Patients with excellent, good, or very good baseline angina-specific quality of life, respectively, were more likely to receive early angiography, even after adjustment, as compared with patients reporting poor baseline quality of life because of angina (62.1.0%, 60.9%, 59.6%, vs 51.2%; adjusted relative risk [RR] = 1.09, 95% confidence interval [CI] 1.04 to 1.16; RR = 1.13, 95% CI 1.01 to 1.27; RR 1.14, 95% CI 0.99 to 1.31, respectively). Finally, patients with a GRACE score in the highest risk decile (199.5 to <321.4) had significantly lower rates of early invasive treatment (42.7%) than patients in the lowest decile of risk (67.6%; adjusted RR for continuous GRACE score per SD [1 SD = 40 points], 0.96, 95% CI 0.92 to 0.99, p = 0.019). In conclusion, in this real-world NSTEMI cohort, patients with the highest mortality risk and worst health status were less likely to be referred for early invasive management. Further work is needed to understand the role of preinfarct health status

Psychological but not vasomotor symptoms are associated with temperament and character traits.

PubMed

Kokras, N; Papadopoulos, L; Zervas, I M; Spyropoulou, A; Stamatelopoulos, K; Rizos, D; Creatsa, M; Augoulea, A; Papadimitriou, G N; Lambrinoudaki, I

2014-08-01

Recent evidence suggests that climacteric symptoms may be intensified by specific temperament and personality traits in postmenopausal women. In this study we investigate Cloninger's model of personality in relation to menopausal symptoms. One-hundred and seventy peri- and postmenopausal women consecutively recruited from a menopause clinic of an academic hospital completed the Cloninger's Temperament and Character Inventory (TCI-140) which measures four dimensions of temperament: Harm avoidance, Novelty seeking, Reward dependence and Persistence, as well as three dimensions of character: Self-directedness, Cooperativeness, and Self-transcendence. Menopausal somatic, vasomotor and psychological symptoms were also assessed using the Greene Climacteric Scale. In comparison to the norms of the Greek general population, postmenopausal women presented lower scores in Novelty seeking and Reward dependence and higher scores in Persistence, Self-directedness, Cooperativeness and Self-transcendence. Higher harm avoidance (the inclination to avoid potential punishment, be shy and fearful of uncertainty) significantly correlated with anxiety and depressive symptoms while lower Self-directedness (the ability to have the willpower to adapt to or overcome any changes) correlated with depressive symptoms only. By multivariate regression analysis, higher Harm avoidance and lower Self-directedness were independently associated with the presence of depressive symptoms. No significant associations were observed between TCI-140 traits and somatic or vasomotor symptoms. Our findings indicate that most temperament and character traits according to Cloninger's model in peri- and postmenopausal women varied significantly as compared to the general population. Among several traits, high Harm avoidance and low Self-directedness were most strongly associated with psychological climacteric distress but not with somatic and vasomotor symptoms.

Effect of engineered nanoparticles on vasomotor responses in rat intrapulmonary artery

DOE Office of Scientific and Technical Information (OSTI.GOV)

Courtois, Arnaud, E-mail: arnaud.courtois@u-bordeaux2.f; Inserm, U885, Bordeaux, F-33076; Andujar, Pascal

2010-06-01

Pulmonary circulation could be one of the primary vascular targets of finest particles that can deeply penetrate into the lungs after inhalation. We investigated the effects of engineered nanoparticles on vasomotor responses of small intrapulmonary arteries using isometric tension measurements. Acute in vitro exposure to carbon nanoparticles (CNP) decreased, and in some case abolished, the vasomotor responses induced by several vasoactive agents, whereas acute exposure to titanium dioxide nanoparticles (TiO{sub 2}NP) did not. This could be attributed to a decrease in the activity of those vasoactive agents (including PGF{sub 2{alpha}}, serotonin, endothelin-1 and acetylcholine), as suggested when they were exposedmore » to CNP before being applied to arteries. Also, CNP decreased the contraction induced by 30 mM KCl, without decreasing its activity. After endoplasmic reticulum calcium stores depletion (by caffeine and thapsigargin), CaCl{sub 2} addition induced a contraction, dependent on Store-Operated Calcium Channels that was not modified by acute CNP exposure. Further addition of 30 mM KCl elicited a contraction, originating from activation of Voltage-Operated Calcium Channels that was diminished by CNP. Contractile responses to PGF{sub 2{alpha}} or KCl, and relaxation to acetylcholine were modified neither in pulmonary arteries exposed in vitro for prolonged time to CNP or TiO{sub 2}NP, nor in those removed from rats intratracheally instilled with CNP or TiO{sub 2}NP. In conclusion, prolonged in vitro or in vivo exposure to CNP or TiO{sub 2}NP does not affect vasomotor responses of pulmonary arteries. However, acute exposure to CNP decreases contraction mediated by activation of Voltage-Operated, but not Store-Operated, Calcium Channels. Moreover, interaction of some vasoactive agents with CNP decreases their biological activity that might lead to misinterpretation of experimental data.« less

Mind-body interventions for vasomotor symptoms in healthy menopausal women and breast cancer survivors. A systematic review.

PubMed

Stefanopoulou, Evgenia; Grunfeld, Elizabeth Alice

2017-09-01

Mind-body therapies are commonly recommended to treat vasomotor symptoms, such as hot flushes and night sweats (HFNS). The purpose of this systematic review was to evaluate the available evidence to date for the efficacy of different mind-body therapies to alleviate HFNS in healthy menopausal women and breast cancer survivors. Randomized controlled trials (RCTs) were identified using seven electronic search engines, direct searches of specific journals and backwards searches through reference lists of related publications. Outcome measures included HFNS frequency and/or severity or self-reported problem rating at post-treatment. The methodological quality of all studies was systematically assessed using predefined criteria. Twenty-six RCTs met the inclusion criteria. Interventions included yoga (n = 5), hypnosis (n = 3), mindfulness (n = 2), relaxation (n = 7), paced breathing (n = 4), reflexology (n = 1) and cognitive behavioural therapy (CBT) (n = 4). Findings were consistent for the effectiveness of CBT and relaxation therapies for alleviating troublesome vasomotor symptoms. For the remaining interventions, although some trials indicated beneficial effects (within groups) at post-treatment and/or follow up, between group findings were mixed and overall, methodological differences across studies failed to provide convincing supporting evidence. Collectively, findings suggest that interventions that include breathing and relaxation techniques, as well as CBT, can be beneficial for alleviating vasomotor symptoms. Additional large, methodologically rigorous trials are needed to establish the efficacy of interventions on vasomotor symptoms, examine long-term outcomes and understand how they work.

Sudomotor and vasomotor activity during the menstrual cycle with global heating.

PubMed

Petrofsky, Jerrold; Lee, Haneul; Khowailed, Iman Akef

2017-07-01

Many studies have reported that there are changes in sympathetic activity throughout the menstrual cycle as there are oestrogen receptor in the hypothalamus and all other parts of the sympathetic nervous system. The purpose of this study was to see whether there were variations in sympathetic activity, skin vasomotor and sweat gland sudomotor rhythms during the menstrual cycle. Eight young female subjects with a regular menstrual cycle participated in the study. Subjects were tested once during the follicular phase and once during the luteal phase. Skin blood flow and sweat rate were significantly higher in the luteal phase compared with the follicular phase (p < .05), but the frequency and magnitude of sudomotor and vasomotor rhythms were significantly greater in the follicular phase (p < .05). In contrast, spectral data showed less sympathetic activity in the luteal phase. A significant finding here is that the sudomotor rhythm of sweat glands is altered by the menstrual cycle. © 2015 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd.

Regulation of coronary resistance vessel tone in response to exercise.

PubMed

Duncker, Dirk J; Bache, Robert J; Merkus, Daphne

2012-04-01

Exercise is a primary stimulus for increased myocardial oxygen demand. The ~6-fold increase in oxygen demand of the left ventricle during heavy exercise is met principally by augmenting coronary blood flow (~5-fold), as hemoglobin concentration and oxygen extraction (which is already ~70% at rest) increase only modestly in most species. As a result, coronary blood flow is tightly coupled to myocardial oxygen consumption over a wide range of physical activity. This tight coupling has been proposed to depend on periarteriolar oxygen tension, signals released from cardiomyocytes and the endothelium as well as neurohumoral influences, but the contribution of each of these regulatory pathways, and their interactions, to exercise hyperemia in the heart remain incompletely understood. In humans, nitric oxide, adenosine and K(ATP) channels each appear to contribute to resting coronary resistance vessel tone, but evidence for a critical contribution to exercise hyperemia is lacking. In dogs K(ATP)-channel activation together with adenosine and nitric oxide contribute to exercise hyperemia in a non-linear redundant fashion. In contrast, in swine nitric oxide, adenosine and K(ATP) channels contribute to resting coronary resistance vessel tone control in a linear additive manner, but do not appear to be mandatory for exercise hyperemia. Rather, exercise hyperemia in swine appears to involve β-adrenergic activation in conjunction with exercise-induced blunting of an endothelin-mediated vasoconstrictor influence. In view of these remarkable species differences in coronary vasomotor control during exercise, future studies are required to determine the system of vasodilator components that mediate exercise hyperemia in humans. This article is part of a Special Issue entitled "Coronary Blood Flow". Copyright © 2011 Elsevier Ltd. All rights reserved.

Long-term prognosis of chronic kidney disease in non-ST elevation acute coronary syndrome treated with invasive strategy.

PubMed

Roldán Torres, Ildefonso; Salvador Mercader, Inmaculada; Cabadés Rumbeu, Claudia; Díez Gil, José Luis; Ferrando Cervelló, José; Monteagudo Viana, Marta; Fernández Galera, Rubén; Mora Llabata, Vicente

Patients with chronic kidney disease (CKD) have an increased risk of adverse cardiovascular outcomes after non-ST elevation acute coronary syndrome (NSTEACS). However, the information available on this specific population, is scarce. We evaluate the impact of CKD on long-term prognosis in patients with NSTEACS managed with invasive strategy. We conduct a prospective registry of patients with NSTEACS and coronary angiography. CKD was defined as a glomerular filtration rate < 60ml/min/1,73m 2 . The composite primary end-point was cardiac death and non fatal cardiovascular readmission. We estimated the cumulative probability and hazard rate (HR) of combined primary end-point at 3-years according to the presence or absence of CKD. We included 248 p with mean age of 66.9 years, 25% women. CKD was present at baseline in 67 patients (27%). Patients with CKD were older (74.9 vs. 63.9 years; P<.0001) with more prevalence of hypertension (89.6 vs. 66.3%; P<.0001), diabetes (53.7 vs. 35.9%; P=.011), history of heart failure (13.4 vs. 3.9%; P=.006) and anemia (47.8 vs. 16%; P<.0001). No differences in the extent of coronary artery disease. CKD was associated with higher cumulative probability (49.3 vs. 28.2%; log-rank P=.001) and HR of the primary combined end-point (HR: 1.94; CI95%: 1.12-3.27; P=.012). CKD was an independent predictor of adverse cardiovascular outcomes at 3-years (HR: 1.66; CI95%: 1.05-2.61; P=.03). In NSTEACS patients treated with invasive strategie CKD is associated independently with an increased risk of adverse cardiovascular outcomes at 3years. Copyright © 2016 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.

Peripheral vasomotor activity assessment using a continuous wavelet analysis on webcam photoplethysmographic signals.

PubMed

Bousefsaf, F; Maaoui, C; Pruski, A

2016-11-25

Vasoconstriction and vasodilation phenomena reflect the relative changes in the vascular bed. They induce particular modifications in the pulse wave magnitude. Webcams correspond to remote sensors that can be employed to measure the pulse wave in order to compute the pulse frequency. Record and analyze pulse wave signal with a low-cost webcam to extract the amplitude information and assess the vasomotor activity of the participant. Photoplethysmographic signals obtained from a webcam are analyzed through a continuous wavelet transform. The performance of the proposed filtering technique was evaluated using approved contact probes on a set of 12 healthy subjects after they perform a short but intense physical exercise. During the rest period, a cutaneous vasodilation is observable. High degrees of correlation between the webcam and a reference sensor were obtained. Webcams are low-cost and non-contact devices that can be used to reliably estimate both heart rate and peripheral vasomotor activity, notably during physical exertion.

Coronary artery wall imaging.

PubMed

Keegan, Jennifer

2015-05-01

Like X-Ray contrast angiography, MR coronary angiograms show the vessel lumens rather than the vessels themselves. Consequently, outward remodeling of the vessel wall, which occurs in subclinical coronary disease before luminal narrowing, cannot be seen. The current gold standard for assessing the coronary vessel wall is intravascular ultrasound, and more recently, optical coherence tomography, both of which are invasive and use ionizing radiation. A noninvasive, low-risk technique for assessing the vessel wall would be beneficial to cardiologists interested in the early detection of preclinical disease and for the safe monitoring of the progression or regression of disease in longitudinal studies. In this review article, the current state of the art in MR coronary vessel wall imaging is discussed, together with validation studies and recent developments. © 2014 Wiley Periodicals, Inc.

Danish study of Non-Invasive testing in Coronary Artery Disease (Dan-NICAD): study protocol for a randomised controlled trial.

PubMed

Nissen, Louise; Winther, Simon; Isaksen, Christin; Ejlersen, June Anita; Brix, Lau; Urbonaviciene, Grazina; Frost, Lars; Madsen, Lene Helleskov; Knudsen, Lars Lyhne; Schmidt, Samuel Emil; Holm, Niels Ramsing; Maeng, Michael; Nyegaard, Mette; Bøtker, Hans Erik; Bøttcher, Morten

2016-05-26

Coronary computed tomography angiography (CCTA) is an established method for ruling out coronary artery disease (CAD). Most patients referred for CCTA do not have CAD and only approximately 20-30 % of patients are subsequently referred to further testing by invasive coronary angiography (ICA) or non-invasive perfusion evaluation due to suspected obstructive CAD. In cases with severe calcifications, a discrepancy between CCTA and ICA often occurs, leading to the well-described, low-diagnostic specificity of CCTA. As ICA is cost consuming and involves a risk of complications, an optimized algorithm would be valuable and could decrease the number of ICAs that do not lead to revascularization. The primary objective of the Dan-NICAD study is to determine the diagnostic accuracy of cardiac magnetic resonance imaging (CMRI) and myocardial perfusion scintigraphy (MPS) as secondary tests after a primary CCTA where CAD could not be ruled out. The secondary objective includes an evaluation of the diagnostic precision of an acoustic technology that analyses the sound of coronary blood flow. It may potentially provide better stratification prior to CCTA than clinical risk stratification scores alone. Dan-NICAD is a multi-centre, randomised, cross-sectional trial, which will include approximately 2,000 patients without known CAD, who were referred to CCTA due to a history of symptoms suggestive of CAD and a low-risk to intermediate-risk profile, as evaluated by a cardiologist. Patient interview, sound recordings, and blood samples are obtained in connection with the CCTA. All patients with suspected obstructive CAD by CCTA are randomised to either stress CMRI or stress MPS, followed by ICA with fractional flow reserve (FFR) measurements. Obstructive CAD is defined as an FFR below 0.80 or as high-grade stenosis (>90 % diameter stenosis) by visual assessment. Diagnostic performance is evaluated as sensitivity, specificity, predictive values, likelihood ratios, and C statistics

Vasomotor and physical menopausal symptoms are associated with sleep quality.

PubMed

Kim, Min-Ju; Yim, Gyeyoon; Park, Hyun-Young

2018-01-01

Sleep disturbance is one of the common complaints in menopause. This study investigated the relationship between menopausal symptoms and sleep quality in middle-aged women. This cross-sectional observational study involved 634 women aged 44-56 years attending a healthcare center at Kangbuk Samsung Hospitals. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI).Multiple linear regression analysis was performed to assess the associations between Menopause-specific Quality of Life (MENQOL) scores and PSQI scores and Menopause-specific Quality of Life (MENQOL)scores. The mean PSQI score was 3.6±2.3, and the rates of poor sleep quality(PSQI score > 5) in premenopausal, perimenopausal, and postmenopausal women were 14.4%, 18.2%, and 30.2%, respectively. Total PSQI score, specifically the sleep latency, habitual sleep efficiency and sleep disturbances scores, were significantly increased in postmenopausal women. Multiple linear regression analysis adjusted for age, BMI, hypertension, diabetes, smoking, marital status, family income, education, employment status, parity, physical activity, depression symptoms, perceived stress and menopausal status showed that higher PSQI score was positively correlated with higher vasomotor(ß = 0.240, P = 0.020)and physical(ß = 0.572, P<0.001) scores. Vasomotor and physical menopause symptoms was related to poor sleep quality. Effective management strategies aimed at reducing menopausal symptoms may improve sleep quality among women around the time of menopause.

NIKOS II - A System For Non-Invasive Imaging Of Coronary Arteries With Synchrotron Radiation

NASA Astrophysics Data System (ADS)

Dix, Wolf-Rainer; Engelke, Klaus; Heuer, Joachim; Graeff, Walter; Kupper, Wolfram; Lohmann, Michael; Makin, I.; Moechel, Thomas; Reumann, Reinhold

1989-10-01

Aim of the work is the visualization of coronary arteries down to 1 mm diameter with an iodine mass density of 1 mg/cm , thus allowing non-invasive investigations by intravenous injection of the contrast agent. Digital Subtraction Angiography (DSA) in energy subtraction mode (dichromography) is employed for this purpose. The two images Cor subtraction are taken at photon energies just below and above the iodine K-edge (33.17 keV). After subtraction the background contrast - such as bone and soft tissue - is suppressed and the iodinated structures are strongly enhanced because of the abrupt change of absorption at the edge. The two monoenergetic beams (bandwidth about 250 eV) with high intensity (about 1011 photons/mm /s) are only available if synchrotron radiation is used. In HASYLAB at DESY (Hamburg, FRG) the system NIKOS was developed for dichromography. It consists of six main parts: A wiggler beam line, a monochromator which filters the two 12 cm wide beams out of the white synchrotron radiation beam, a fast scanning device, a fast low-noise two-line detector, a safety system and a computer system. At present, one scan (two images) lasts 1 s. The images from the in-vivo investigations of dogs have been promising. The right coronary artery (diameter 1.5 mm) was clearly visible.

Distance to invasive heart centre, performance of acute coronary angiography, and angioplasty and associated outcome in out-of-hospital cardiac arrest: a nationwide study.

PubMed

Tranberg, Tinne; Lippert, Freddy K; Christensen, Erika F; Stengaard, Carsten; Hjort, Jakob; Lassen, Jens Flensted; Petersen, Frants; Jensen, Jan Skov; Bäck, Caroline; Jensen, Lisette Okkels; Ravkilde, Jan; Bøtker, Hans Erik; Terkelsen, Christian Juhl

2017-06-01

To evaluate whether the distance from the site of event to an invasive heart centre, acute coronary angiography (CAG)/percutaneous coronary intervention (PCI) and hospital-level of care (invasive heart centre vs. local hospital) is associated with survival in out-of-hospital cardiac arrest (OHCA) patients. Nationwide historical follow-up study of 41 186 unselected OHCA patients, in whom resuscitation was attempted between 2001 and 2013, identified through the Danish Cardiac Arrest Registry. We observed an increase in the proportion of patients receiving bystander CPR (18% in 2001, 60% in 2013, P < 0.001), achieving return of spontaneous circulation (ROSC) (10% in 2001, 29% in 2013, P < 0.001) and being admitted directly to an invasive centre (26% in 2001, 45% in 2013, P < 0.001). Simultaneously, 30-day survival rose from 5% in 2001 to 12% in 2013, P < 0.001. Among patients achieving ROSC, a larger proportion underwent acute CAG/PCI (5% in 2001, 27% in 2013, P < 0.001). The proportion of patients undergoing acute CAG/PCI annually in each region was defined as the CAG/PCI index. The following variables were associated with lower mortality in multivariable analyses: direct admission to invasive heart centre (HR 0.91, 95% CI: 0.89-0.93), CAG/PCI index (HR 0.33, 95% CI: 0.25-0.45), population density above 2000 per square kilometre (HR 0.94, 95% CI: 0.89-0.98), bystander CPR (HR 0.97, 95% CI: 0.95-0.99) and witnessed OHCA (HR 0.87, 95% CI: 0.85-0.89), whereas distance to the nearest invasive centre was not associated with survival. Admission to an invasive heart centre and regional performance of acute CAG/PCI were associated with improved survival in OHCA patients, whereas distance to the invasive centre was not. These results support a centralized strategy for immediate post-resuscitation care in OHCA patients. © The Author 2017. Published on behalf of the European Society of Cardiology.

Cerebral vasomotor reactivity in neurodegenerative diseases.

PubMed

Smoliński, Łukasz; Członkowska, Anna

Small-caliber cerebral vessels change their diameters in response to alterations of key metabolite concentrations such as carbon dioxide or oxygen. This phenomenon, termed the cerebral vasomotor reactivity (CVMR), is the basis for blood flow regulation in the brain in accordance with its metabolic status. Typically, CVMR is determined as the amount of change in cerebral blood flow in response to a vasodilating stimulus, which can be measured by various neuroimaging methods or by transcranial Doppler. It has been shown that CVMR is impaired in cerebrovascular diseases, but there is also evidence of a similar dysfunction in neurodegenerative disorders. Here, we review studies that have investigated CVMR in the common neurodegenerative diseases such as Alzheimer's disease, Parkinson's disease and multiple sclerosis. Moreover, we discuss potential neurodegenerative mechanisms responsible for the impairment of CVMR. Copyright © 2016 Polish Neurological Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.

Plaque imaging with CT—a comprehensive review on coronary CT angiography based risk assessment

PubMed Central

Kolossváry, Márton; Szilveszter, Bálint; Merkely, Béla

2017-01-01

CT based technologies have evolved considerably in recent years. Coronary CT angiography (CTA) provides robust assessment of coronary artery disease (CAD). Early coronary CTA imaging—as a gate-keeper of invasive angiography—has focused on the presence of obstructive stenosis. Coronary CTA is currently the only non-invasive imaging modality for the evaluation of non-obstructive CAD, which has been shown to contribute to adverse cardiac events. Importantly, improved spatial resolution of CT scanners and novel image reconstruction algorithms enable the quantification and characterization of atherosclerotic plaques. State-of-the-art CT imaging can therefore reliably assess the extent of CAD and differentiate between various plaque features. Recent studies have demonstrated the incremental prognostic value of adverse plaque features over luminal stenosis. Comprehensive coronary plaque assessment holds potential to significantly improve individual risk assessment incorporating adverse plaque characteristics, the extent and severity of atherosclerotic plaque burden. As a result, several coronary CTA based composite risk scores have been proposed recently to determine patients at high risk for adverse events. Coronary CTA became a promising modality for the evaluation of functional significance of coronary lesions using CT derived fractional flow reserve (FFR-CT) and/or rest/dynamic myocardial CT perfusion. This could lead to substantial reduction in unnecessary invasive catheterization procedures and provide information on ischemic burden of CAD. Discordance between the degree of stenosis and ischemia has been recognized in clinical landmark trials using invasive FFR. Both lesion stenosis and composition are possibly related to myocardial ischemia. The evaluation of lesion-specific ischemia using combined functional and morphological plaque information could ultimately improve the diagnostic performance of CTA and thus patient care. In this review we aimed to

Peroxynitrite Disrupts Endothelial Caveolae Leading to eNOS Uncoupling and Diminished Flow-Mediated Dilation in Coronary Arterioles of Diabetic Patients

PubMed Central

Cassuto, James; Dou, Huijuan; Czikora, Istvan; Szabo, Andras; Patel, Vijay S.; Kamath, Vinayak; Belin de Chantemele, Eric; Feher, Attila; Romero, Maritza J.; Bagi, Zsolt

2014-01-01

Peroxynitrite (ONOO−) contributes to coronary microvascular dysfunction in diabetes mellitus (DM). We hypothesized that in DM, ONOO− interferes with the function of coronary endothelial caveolae, which plays an important role in nitric oxide (NO)-dependent vasomotor regulation. Flow-mediated dilation (FMD) of coronary arterioles was investigated in DM (n = 41) and non-DM (n = 37) patients undergoing heart surgery. NO-mediated coronary FMD was significantly reduced in DM patients, which was restored by ONOO− scavenger, iron-(III)-tetrakis(N-methyl-4'pyridyl)porphyrin-pentachloride, or uric acid, whereas exogenous ONOO− reduced FMD in non-DM subjects. Immunoelectron microscopy demonstrated an increased 3-nitrotyrosine formation (ONOO−-specific protein nitration) in endothelial plasma membrane in DM, which colocalized with caveolin-1 (Cav-1), the key structural protein of caveolae. The membrane-localized Cav-1 was significantly reduced in DM and also in high glucose–exposed coronary endothelial cells. We also found that DM patients exhibited a decreased number of endothelial caveolae, whereas exogenous ONOO− reduced caveolae number. Correspondingly, pharmacological (methyl-β-cyclodextrin) or genetic disruption of caveolae (Cav-1 knockout mice) abolished coronary FMD, which was rescued by sepiapterin, the stable precursor of NO synthase (NOS) cofactor, tetrahydrobiopterin. Sepiapterin also restored coronary FMD in DM patients. Thus, we propose that ONOO− selectively targets and disrupts endothelial caveolae, which contributes to NOS uncoupling, and, hence, reduced NO-mediated coronary vasodilation in DM patients. PMID:24353182

Temporal trends in the use of invasive cardiac procedures for non-ST segment elevation acute coronary syndromes according to initial risk stratification

PubMed Central

Jedrzkiewicz, Sean; Goodman, Shaun G; Yan, Raymond T; Welsh, Robert C; Kornder, Jan; DeYoung, J Paul; Wong, Graham C; Rose, Barry; Grondin, François R; Gallo, Richard; Huang, Wei; Gore, Joel M; Yan, Andrew T

2009-01-01

BACKGROUND: Current guidelines support an early invasive strategy in the management of high-risk non-ST elevation acute coronary syndromes (NSTE-ACS). Although studies in the 1990s suggested that high-risk patients received less aggressive treatment, there are limited data on the contemporary management patterns of NSTE-ACS in Canada. OBJECTIVE: To examine the in-hospital use of coronary angiography and revascularization in relation to risk among less selected patients with NSTE-ACS. METHODS: Data from the prospective, multicentre Global Registry of Acute Coronary Events (main GRACE and expanded GRACE2) were used. Between June 1999 and September 2007, 7131 patients from across Canada with a final diagnosis of NSTE-ACS were included the study. The study population was stratified into low-, intermediate- and high-risk groups, based on their calculated GRACE risk score (a validated predictor of in-hospital mortality) and according to time of enrollment. RESULTS: While rates of in-hospital death and reinfarction were significantly (P<0.001) greater in higher-risk patients, the in-hospital use of cardiac catheterization in low- (64.7%), intermediate- (60.3%) and high-risk (42.3%) patients showed an inverse relationship (P<0.001). This trend persisted despite the increase in the overall rates of cardiac catheterization over time (47.9% in 1999 to 2003 versus 51.6% in 2004 to 2005 versus 63.8% in 2006 to 2007; P<0.001). After adjusting for confounders, intermediate-risk (adjusted OR 0.80 [95% CI 0.70 to 0.92], P=0.002) and high-risk (adjusted OR 0.38 [95% CI 0.29 to 0.48], P<0.001) patients remained less likely to undergo in-hospital cardiac catheterization. CONCLUSION: Despite the temporal increase in the use of invasive cardiac procedures, they remain paradoxically targeted toward low-risk patients with NSTE-ACS in contemporary practice. This treatment-risk paradox needs to be further addressed to maximize the benefits of invasive therapies in Canada. PMID:19898699

Invasion of vascular cells in vitro by Porphyromonas endodontalis.

PubMed

Dorn, B R; Harris, L J; Wujick, C T; Vertucci, F J; Progulske-Fox, A

2002-04-01

The objective of this study was to determine whether laboratory strains and clinical isolates of microorganisms associated with root canal infections can invade primary cultures of cardiovascular cells. Quantitative levels of bacterial invasion of human coronary artery endothelial cells (HCAEC) and coronary artery smooth muscle cells (CASMC) were measured using a standard antibiotic protection assay. Transmission electron microscopy was used to confirm and visualize internalization within the vascular cells. Of the laboratory and clinical strains tested, only P. endodontalis ATCC 35406 was invasive in an antibiotic protection assay using HCAEC and CASMC. Invasion of P. endodontalis ATCC 35406 was confirmed by transmission electron microscopy. Certain microorganisms associated with endodontic infections are invasive. If bacterial invasion of the vasculature contributes to the pathogenesis of cardiovascular disease, then microorganisms in the pulp chamber represent potential pathogens.

Costs and clinical outcomes for non-invasive versus invasive diagnostic approaches to patients with suspected in-stent restenosis.

PubMed

Min, James K; Hasegawa, James T; Machacz, Susanne F; O'Day, Ken

2016-02-01

This study compared costs and clinical outcomes of invasive versus non-invasive diagnostic evaluations for patients with suspected in-stent restenosis (ISR) after percutaneous coronary intervention. We developed a decision model to compare 2 year diagnosis-related costs for patients who presented with suspected ISR and were evaluated by: (1) invasive coronary angiography (ICA); (2) non-invasive stress testing strategy of myocardial perfusion imaging (MPI) with referral to ICA based on MPI; (3) coronary CT angiography-based testing strategy with referral to ICA based on CCTA. Costs were modeled from the payer's perspective using 2014 Medicare rates. 56 % of patients underwent follow-up diagnostic testing over 2 years. Compared to ICA, MPI (98.6 %) and CCTA (98.1 %) exhibited lower rates of correct diagnoses. Non-invasive strategies were associated with reduced referrals to ICA and costs compared to an ICA-based strategy, with diagnostic costs lower for CCTA than MPI. Overall 2-year costs were highest for ICA for both metallic as well as BVS stents ($1656 and $1656, respectively) when compared to MPI ($1444 and $1411) and CCTA. CCTA costs differed based upon stent size and type, and were highest for metallic stents >3.0 mm followed by metallic stents <3.0 mm, BVS < 3.0 mm and BVS > 3.0 mm ($1466 vs. $1242 vs. $855 vs. $490, respectively). MPI for suspected ISR results in lower costs and rates of complications than invasive strategies using ICA while maintaining high diagnostic performance. Depending upon stent size and type, CCTA results in lower costs than MPI.

Same-day transfer for the invasive strategy of patients with non-ST-segment elevation acute coronary syndrome admitted to spoke hospitals: Data from the Emilia-Romagna Regional Network.

PubMed

Campo, Gianluca; Menozzi, Mila; Guastaroba, Paolo; Vignali, Luigi; Belotti, Laura Mb; Casella, Gianni; Berti, Elena; Solinas, Emilia; Guiducci, Vincenzo; Biscaglia, Simone; Pavasini, Rita; De Palma, Rossana; Manari, Antonio

2016-10-01

The service strategy (same-day transfer between spoke hospital and hub centre with catheterisation laboratory (cath-lab) facility to perform invasive procedures) has been suggested to improve the management of patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) admitted to spoke hospitals. We used data from a large prospective Italian registry to describe application, performance and outcome of the service strategy in the daily clinical practice. This study was based on an observational, post-hoc analysis of all consecutive NSTEACS patients admitted to spoke non-invasive hospitals of the Emilia-Romagna regional network and receiving coronary artery angiography (CAA)±percutaneous coronary intervention (PCI). We evaluated: application of service strategy, time to cath-lab access, hospital stay length, 30-days occurrence of adverse events. From January 2011-December 2012, 2952 NSTEACS consecutive patients were admitted to spoke non-invasive hospitals and received CAA. Overall, 1765 (60%) patients were managed with a service strategy. After multivariable analysis, service strategy emerged as independent predictor of faster access to cath-lab (within 72 h: hazard ratio (HR) 2.3, 95% confidence interval (CI) 1.9-2.7, p<0.0001; within 24 h: HR 2.8, 95% CI 2.2-3.3, p<0.0001, respectively). Service strategy significantly reduced hospital stay length (-5.5 days, p<0.0001). We estimated a mean of €1590 saved for each patient managed with service strategy. Thirty-day occurrence of adverse events did not differ between patients managed with or without a service strategy. In our daily clinical practice, a service strategy seems to be an effective approach to optimise the invasive management of NSTEACS patients admitted to spoke hospitals. © The European Society of Cardiology 2015.

Is there a role for robotic totally endoscopic coronary artery bypass in patients with a colostomy?

PubMed

Gibber, Marc; Lehr, Eric J; Kon, Zachary N; Wehman, P Brody; Griffith, Bartley P; Bonatti, Johannes

2014-01-01

Preoperative colostomy presents a significant risk of sternal wound complications, mediastinitis, and ostomy injury in patients requiring coronary artery bypass grafting. Less invasive procedures in coronary surgery have a potential to reduce the risk of sternal wound healing problems. Robotic totally endoscopic coronary artery bypass grafting in patients with a colostomy has not been reported. We describe a case of completely endoscopic coronary surgery using the da Vinci Si system in a patient with a transverse colostomy. Single left internal mammary artery grafting to the left anterior coronary artery was performed successfully on the beating heart. We regard this technique as the least invasive method of surgical coronary revascularization with a potential to reduce the risk of surgical site infection and mediastinitis in patients with a colostomy.

Accuracy of MSCT Coronary Angiography with 64 Row CT Scanner—Facing the Facts

PubMed Central

Wehrschuetz, M.; Wehrschuetz, E.; Schuchlenz, H.; Schaffler, G.

2010-01-01

Improvements in multislice computed tomography (MSCT) angiography of the coronary vessels have enabled the minimally invasive detection of coronary artery stenoses, while quantitative coronary angiography (QCA) is the accepted reference standard for evaluation thereof. Sixteen-slice MSCT showed promising diagnostic accuracy in detecting coronary artery stenoses haemodynamically and the subsequent introduction of 64-slice scanners promised excellent and fast results for coronary artery studies. This prompted us to evaluate the diagnostic accuracy, sensitivity, specificity, and the negative und positive predictive value of 64-slice MSCT in the detection of haemodynamically significant coronary artery stenoses. Thirty-seven consecutive subjects with suspected coronary artery disease were evaluated with MSCT angiography and the results compared with QCA. All vessels were considered for the assessment of significant coronary artery stenosis (diameter reduction ≥ 50%). Thirteen patients (35%) were identified as having significant coronary artery stenoses on QCA with 6.3% (35/555) affected segments. None of the coronary segments were excluded from analysis. Overall sensitivity for classifying stenoses of 64-slice MSCT was 69%, specificity was 92%, positive predictive value was 38% and negative predictive value was 98%. The interobserver variability for detection of significant lesions had a k-value of 0.43. Sixty-four-slice MSCT offers the diagnostic potential to detect coronary artery disease, to quantify haemodynamically significant coronary artery stenoses and to avoid unnecessary invasive coronary artery examinations. PMID:20567636

Fractional flow reserve by computerized tomography and subsequent coronary revascularization

PubMed Central

Packard, René R. Sevag; Li, Dong; Budoff, Matthew J.; Karlsberg, Ronald P.

2017-01-01

Aims Fractional flow reserve by computerized tomography (FFR-CT) provides non-invasive functional assessment of the hemodynamic significance of coronary artery stenosis. We determined the FFR-CT values, receiver operator characteristic (ROC) curves, and predictive ability of FFR-CT for actual standard of care guided coronary revascularization. Methods and results Consecutive outpatients who underwent coronary CT angiography (coronary CTA) followed by invasive angiography over a 24-month period from 2012 to 2014 were identified. Studies that fit inclusion criteria (n = 75 patients, mean age 66, 75% males) were sent for FFR-CT analysis, and results stratified by coronary artery calcium (CAC) scores. Coronary CTA studies were re-interpreted in a blinded manner, and baseline FFR-CT values were obtained retrospectively. Therefore, results did not interfere with clinical decision-making. Median FFR-CT values were 0.70 in revascularized (n = 69) and 0.86 in not revascularized (n = 138) coronary arteries (P < 0.001). Using clinically established significance cut-offs of FFR-CT ≤0.80 and coronary CTA ≥70% stenosis for the prediction of clinical decision-making and subsequent coronary revascularization, the positive predictive values were 74 and 88% and negative predictive values were 96 and 84%, respectively. The area under the curve (AUC) for all studied territories was 0.904 for coronary CTA, 0.920 for FFR-CT, and 0.941 for coronary CTA combined with FFR-CT (P = 0.001). With increasing CAC scores, the AUC decreased for coronary CTA but remained higher for FFR-CT (P < 0.05). Conclusion The addition of FFR-CT provides a complementary role to coronary CTA and increases the ability of a CT-based approach to identify subsequent standard of care guided coronary revascularization. PMID:27469588

Vascular connector devices increase the availability of minimally invasive cardiac surgery to ischemic heart patients.

PubMed

Ramchandani, M; Bedeir, K

2011-01-01

The revival of off-pump cardiac surgery and the exploration of less invasive techniques for coronary artery bypass grafting, have lead to an increasing technical difficulty, as compared to conventional surgery using cardiopulmonary bypass. The moving target vessel in off-pump coronary artery bypass surgery, as well as the increasingly limited space in minimally invasive cardiac surgery were not convenient to many surgeons, a fact that lead many surgeons to deprive their patients the potential benefits of these techniques. Since the 1950's, surgeons have attempted to make the anastomotic procedure less cumbersome and less time consuming. Many creative ideas and devices were made, but for many different reasons, they eventually faded away. Since then, hand-sewn anastomoses have been the standard of care in coronary artery bypass grafting. Today, with the obvious need for a facilitated and fast coronary anastomosis, interest in these anastomotic devices has been re-awakened. The exact geometry, physiology and dynamics of the perfect anastomosis have thus been studied, in an attempt to provide an understanding of reasons behind anastomosis and graft failure after coronary artery bypass surgery, and eventually design the best performing device. These devices would allow for a faster, more accurate and a more reproducible coronary anastomosis using minimally invasive techniques. Also, due to a short learning curve, the standardization of percutaneous devices would allow much more surgeons to more widely adopt less invasive techniques. In summary, we see anastomotic devices as a solution to the technical challenges surgeons encounter with minimally invasive coronary artery bypass grafting.

Assessment of coronary artery stenosis pressure gradient by quantitative coronary arteriography in patients with coronary artery disease.

PubMed

Atar, D; Ramanujam, P S; Saunamäki, K; Haunsø, S

1994-01-01

The aim of the study described here was to correlate coronary artery (CA) stenosis pressure gradients calculated by quantitative coronary arteriography (QCA) to invasively measured transstenotic pressure drops in patients with anginal symptoms and with known or suspected coronary artery disease. Furthermore, the known mathematical models are improved by introducing (1) pressure catheter-corrected minimal stenosis area, (2) modification of flow assumptions, and (3) stenosis exit angle. Included in the study were 45 patients with 61 stenoses. The visually estimated CA lesion severity in these non-complex stenoses was in the equivocal range of 40-70%. All measurements were performed after intracoronary administration of nifedipine and nitroglycerin. Stenosis dimensions were assessed from magnified cinefilms, using hand-held calipers. Highly significant overall correlation was found between measured and calculated pressure gradients with correction for the impact of the intracoronary catheter (P < 0.00001, r = 0.84). In particular, a substantial number of stenoses with haemodynamically-insignificant pressure gradients were identified by hydrodynamic calculations. In conclusion, the great majority of the coronary artery stenoses could be classified reliably by QCA as being haemodynamically insignificant or significant, respectively.

CAD-RADS - a new clinical decision support tool for coronary computed tomography angiography.

PubMed

Foldyna, Borek; Szilveszter, Bálint; Scholtz, Jan-Erik; Banerji, Dahlia; Maurovich-Horvat, Pál; Hoffmann, Udo

2018-04-01

Coronary computed tomography angiography (CTA) has been established as an accurate method to non-invasively assess coronary artery disease (CAD). The proposed 'Coronary Artery Disease Reporting and Data System' (CAD-RADS) may enable standardised reporting of the broad spectrum of coronary CTA findings related to the presence, extent and composition of coronary atherosclerosis. The CAD-RADS classification is a comprehensive tool for summarising findings on a per-patient-basis dependent on the highest-grade coronary artery lesion, ranging from CAD-RADS 0 (absence of CAD) to CAD-RADS 5 (total occlusion of a coronary artery). In addition, it provides suggestions for clinical management for each classification, including further testing and therapeutic options. Despite some limitations, CAD-RADS may facilitate improved communication between imagers and patient caregivers. As such, CAD-RADS may enable a more efficient use of coronary CTA leading to more accurate utilisation of invasive coronary angiograms. Furthermore, widespread use of CAD-RADS may facilitate registry-based research of diagnostic and prognostic aspects of CTA. • CAD-RADS is a tool for standardising coronary CTA reports. • CAD-RADS includes clinical treatment recommendations based on CTA findings. • CAD-RADS has the potential to reduce variability of CTA reports.

Flow in the left anterior descending coronary artery in patients with migraine headache.

PubMed

Aslan, Gamze; Sade, Leyla Elif; Yetis, Begum; Bozbas, Huseyin; Eroglu, Serpil; Pirat, Bahar; Can, Ufuk; Muderrisoglu, Haldun

2013-11-15

Migraine is a common neurovascular disorder characterized by attacks of severe headache, autonomic and neurologic symptoms. Migraine can affect many systems in the body, yet its effects on cardiovascular system are unclear. We hypothesized that migraine and coronary microvascular angina may be manifestations of a common systemic microvascular dysfunction and clinically associated. Forty patients with migraine and 35 healthy volunteers were included into the study. Using transthoracic Doppler echocardiography, coronary flow was visualized in the middle or distal part of the left anterior descending artery. Coronary diastolic peak flow velocities were measured with pulse wave Doppler at baseline and after dipyridamole infusion (0.56 mg/kg/4 min). Coronary flow reserve of <2 was considered normal. In addition, thorough 2-dimensional and Doppler echocardiographic examinations were also performed. Fifty-two women and 23 men were included. Coronary flow reserve was significantly lesser in the migraine group than in the control group (1.99 ± 0.3 vs 2.90 ± 0.5, p <0.05). In addition, mitral annular velocities were lower and the ratio of early mitral inflow velocity to early mitral annular velocity (E/E' lateral and E/E' septal) was higher in migraineurs than in the control group (p <0.05 for all), indicating diastolic function abnormalities in the migraine group. In conclusion, these findings suggest that there is an association between coronary microvascular dysfunction and migraine independently of the metabolic state of the patients. A common pathophysiologic pathway of impaired endothelial vasodilatation, vasomotor dysfunction, and increased systemic inflammatory factors may play a role in these 2 clinical conditions and could be the underlying cause of subclinical systolic and diastolic left ventricular dysfunction in migraineurs. Copyright © 2013 Elsevier Inc. All rights reserved.

Endothelial Arginine Resynthesis Contributes to the Maintenance of Vasomotor Function in Male Diabetic Mice

PubMed Central

Chennupati, Ramesh; Meens, Merlijn J. P. M. T.; Marion, Vincent; Janssen, Ben J.; Lamers, Wouter H.; De Mey, Jo G. R.; Köhler, S. Eleonore

2014-01-01

Aim Argininosuccinate synthetase (ASS) is essential for recycling L-citrulline, the by-product of NO synthase (NOS), to the NOS substrate L-arginine. Here, we assessed whether disturbed arginine resynthesis modulates endothelium-dependent vasodilatation in normal and diabetic male mice. Methods and Results Endothelium-selective Ass-deficient mice (Assfl/fl/Tie2Cretg/− = Ass-KOTie2) were generated by crossing Assfl/fl mice ( = control) with Tie2Cre mice. Gene ablation in endothelial cells was confirmed by immunohistochemistry. Blood pressure (MAP) was recorded in 34-week-old male mice. Vasomotor responses were studied in isolated saphenous arteries of 12- and 34-week-old Ass-KOTie2 and control animals. At the age of 10 weeks, diabetes was induced in control and Ass-KOTie2 mice by streptozotocin injections. Vasomotor responses of diabetic animals were studied 10 weeks later. MAP was similar in control and Ass-KOTie2 mice. Depletion of circulating L-arginine by arginase 1 infusion or inhibition of NOS activity with L-NAME resulted in an increased MAP (10 and 30 mmHg, respectively) in control and Ass-KOTie2 mice. Optimal arterial diameter, contractile responses to phenylephrine, and relaxing responses to acetylcholine and sodium nitroprusside were similar in healthy control and Ass-KOTie2 mice. However, in diabetic Ass-KOTie2 mice, relaxation responses to acetylcholine and endothelium-derived NO (EDNO) were significantly reduced when compared to diabetic control mice. Conclusions Absence of endothelial citrulline recycling to arginine did not affect blood pressure and systemic arterial vasomotor responses in healthy mice. EDNO-mediated vasodilatation was significantly more impaired in diabetic Ass-KOTie2 than in control mice demonstrating that endothelial arginine recycling becomes a limiting endothelial function in diabetes. PMID:25033204

Vasomotor symptoms and cardiometabolic risk factors in menopausal women: a MONET Group study.

PubMed

Abdulnour, J; Stacey, D; Dionne, I J; Brochu, M; Doucet, É; Prud'homme, D

2016-08-01

Conflicting results have been reported concerning the prevalence of cardiometabolic risk factors in women experiencing vasomotor symptoms (VMS). To compare cardiometabolic risk factors between women with and without VMS during the menopause transition and to determine the influence of physical activity on the prevalence of VMS. Yearly assessment of women transitioning through menopause included self-reported VMS (hot flushes and night sweats), body composition and fat distribution, fasting glucose, insulin and lipids, and physical activity levels. Eighty-five of the 102 premenopausal women at baseline were included (age: 49.9 ± 2.0 years; body mass index: 23.2 ± 2.2 kg/m(2)). According to linear mixed model analyses, no statistically significant differences were observed for fat mass, lean body mass, body fat distribution indices and cardiometabolic risk factors, when comparing symptomatic vs. asymptomatic women. Neither physical activity levels nor intensity were associated with the prevalence of VMS. Our results suggest that women transitioning through menopause who reported VMS did not show greater deteriorations in body composition, body fat distribution and cardiometabolic risk factors. Furthermore, physical activity levels were not associated with lower prevalence of vasomotor symptoms in the present cohort.

What causes hot flushes? The neuroendocrine origin of vasomotor symptoms in the menopause.

PubMed

Rossmanith, Winfried G; Ruebberdt, Wiebke

2009-05-01

Vasomotor symptoms (VMS) such as hot flushes and night sweats are frequently encountered during menopause and can greatly reduce the quality of life. These symptoms are causally related to decreasing estradiol concentrations, mainly in the serum and subsequently also in the hypothalamic temperature regulating centre. The lack of estrogens alters neurotransmitter activity, especially in the serotonergic and noradrenergic pathways. Because sex steroids act as potent neuromodulators, the substitution of ovarian sex steroids by hormone replacement therapy is the most effective treatment option for VMS. When contraindications exist for the use of sex steroids, steroid-free drugs are a possible alternative. A better understanding of the physiology of thermoregulation, thermoregulatory dysfunction and adaptive processes of the brain may facilitate the development of new therapeutic approaches. Such drugs could then be used to treat vasomotor disorders even when the use of steroid hormones is contraindicated. This review article summarises our knowledge on the mechanisms of temperature regulation and describes deviations from this regulation during altered sex steroid conditions. Our current knowledge on neuroendocrinology of thermoregulation may serve as a basis for the use of steroid-free pharmacological intervention.

Calcium score of coronary artery stratifies the risk of obstructive coronary artery diseases.

PubMed

Ibrahim, O; Oteh, M; Anwar, I R; Che Hassan, H H; Choor, C K; Hamzaini, A H; Rahman, M M

2013-01-01

Coronary heart disease is a major health problem in Malaysia with high morbidity and mortality. Common primary screening tool of cardiovascular risk stratification is exercise treadmill test (ETT). This communication is to determine the performance of coronary artery calcium score a new method to stratify the presence of obstructive coronary artery disease (CAD) in comparison to traditional ETT in patients having coronary artery diseases. Patients between 30 to 60 years old attended the ETT to screen for ischemic heart disease were recruited for Agatston coronary artery calcium score (CACS) of multi-sliced computed tomography (MSCT). Subsequently all patients underwent a full MSCT coronary angiography. The major determinant was the state of CAD whether obstructive (50% stenosis or more) or non-obstructive (less than 50% stenosis). All patients diagnosed with obstructive CAD on MSCT coronary angiogram were subjected to invasive coronary angiogram (ICA) to confirm the findings and planned the need for revascularization. The CACS was 100% sensitivity and 97.5% specificity in detecting obstructive CAD at the optimal cut-off value of 106.5 and above. The positive predictive value (PPV) at CACS ≥ 106 was 71.4% and the negative predictive value (NPV) was consistent at 100%. Compare to ETT, the CACS discriminative value and diagnostic performance was much better (PPV 71.4% vs. 45.5%), respectively. CACS can be a good diagnostic screening tool in patients suspected of CAD, and particularly within the non-diagnostic ETT subgroup with low to moderate cardiovascular risks.

The collagen-binding protein Cnm is required for Streptococcus mutans adherence to and intracellular invasion of human coronary artery endothelial cells.

PubMed

Abranches, Jacqueline; Miller, James H; Martinez, Alaina R; Simpson-Haidaris, Patricia J; Burne, Robert A; Lemos, José A

2011-06-01

Streptococcus mutans is considered the primary etiologic agent of dental caries, a global health problem that affects 60 to 90% of the population, and a leading causative agent of infective endocarditis. It can be divided into four different serotypes (c, e, f, and k), with serotype c strains being the most common in the oral cavity. In this study, we demonstrate that in addition to OMZ175 and B14, three other strains (NCTC11060, LM7, and OM50E) of the less prevalent serotypes e and f are able to invade primary human coronary artery endothelial cells (HCAEC). Invasive strains were also significantly more virulent than noninvasive strains in the Galleria mellonella (greater wax worm) model of systemic disease. Interestingly, the invasive strains carried an additional gene, cnm, which was previously shown to bind to collagen and laminin in vitro. Inactivation of cnm rendered the organisms unable to invade HCAEC and attenuated their virulence in G. mellonella. Notably, the cnm knockout strains did not adhere to HCAEC as efficiently as the parental strains did, indicating that the loss of the invasion phenotype observed for the mutants was linked to an adhesion defect. Comparisons of the invasive strains and their respective cnm mutants did not support a correlation between biofilm formation and invasion. Thus, Cnm is required for S. mutans invasion of endothelial cells and possibly represents an important virulence factor of S. mutans that may contribute to cardiovascular infections and pathologies.

Deep learning analysis of the myocardium in coronary CT angiography for identification of patients with functionally significant coronary artery stenosis.

PubMed

Zreik, Majd; Lessmann, Nikolas; van Hamersvelt, Robbert W; Wolterink, Jelmer M; Voskuil, Michiel; Viergever, Max A; Leiner, Tim; Išgum, Ivana

2018-02-01

In patients with coronary artery stenoses of intermediate severity, the functional significance needs to be determined. Fractional flow reserve (FFR) measurement, performed during invasive coronary angiography (ICA), is most often used in clinical practice. To reduce the number of ICA procedures, we present a method for automatic identification of patients with functionally significant coronary artery stenoses, employing deep learning analysis of the left ventricle (LV) myocardium in rest coronary CT angiography (CCTA). The study includes consecutively acquired CCTA scans of 166 patients who underwent invasive FFR measurements. To identify patients with a functionally significant coronary artery stenosis, analysis is performed in several stages. First, the LV myocardium is segmented using a multiscale convolutional neural network (CNN). To characterize the segmented LV myocardium, it is subsequently encoded using unsupervised convolutional autoencoder (CAE). As ischemic changes are expected to appear locally, the LV myocardium is divided into a number of spatially connected clusters, and statistics of the encodings are computed as features. Thereafter, patients are classified according to the presence of functionally significant stenosis using an SVM classifier based on the extracted features. Quantitative evaluation of LV myocardium segmentation in 20 images resulted in an average Dice coefficient of 0.91 and an average mean absolute distance between the segmented and reference LV boundaries of 0.7 mm. Twenty CCTA images were used to train the LV myocardium encoder. Classification of patients was evaluated in the remaining 126 CCTA scans in 50 10-fold cross-validation experiments and resulted in an area under the receiver operating characteristic curve of 0.74 ± 0.02. At sensitivity levels 0.60, 0.70 and 0.80, the corresponding specificity was 0.77, 0.71 and 0.59, respectively. The results demonstrate that automatic analysis of the LV myocardium in a single

Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials.

PubMed

Jobs, Alexander; Mehta, Shamir R; Montalescot, Gilles; Vicaut, Eric; Van't Hof, Arnoud W J; Badings, Erik A; Neumann, Franz-Josef; Kastrati, Adnan; Sciahbasi, Alessandro; Reuter, Paul-Georges; Lapostolle, Frédéric; Milosevic, Aleksandra; Stankovic, Goran; Milasinovic, Dejan; Vonthein, Reinhard; Desch, Steffen; Thiele, Holger

2017-08-19

A routine invasive strategy is recommended for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, optimal timing of invasive strategy is less clearly defined. Individual clinical trials were underpowered to detect a mortality benefit; we therefore did a meta-analysis to assess the effect of timing on mortality. We identified randomised controlled trials comparing an early versus a delayed invasive strategy in patients presenting with NSTE-ACS by searching MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. We included trials that reported all-cause mortality at least 30 days after in-hospital randomisation and for which the trial investigators agreed to collaborate (ie, providing individual patient data or standardised tabulated data). We pooled hazard ratios (HRs) using random-effects models. This meta-analysis is registered at PROSPERO (CRD42015018988). We included eight trials (n=5324 patients) with a median follow-up of 180 days (IQR 180-360). Overall, there was no significant mortality reduction in the early invasive group compared with the delayed invasive group HR 0·81, 95% CI 0·64-1·03; p=0·0879). In pre-specified analyses of high-risk patients, we found lower mortality with an early invasive strategy in patients with elevated cardiac biomarkers at baseline (HR 0·761, 95% CI 0·581-0·996), diabetes (0·67, 0·45-0·99), a GRACE risk score more than 140 (0·70, 0·52-0·95), and aged 75 years older (0·65, 0·46-0·93), although tests for interaction were inconclusive. An early invasive strategy does not reduce mortality compared with a delayed invasive strategy in all patients with NSTE-ACS. However, an early invasive strategy might reduce mortality in high-risk patients. None. Copyright © 2017 Elsevier Ltd. All rights reserved.

Invasive strategy in non-ST-segment elevation acute coronary syndrome: What should be the benchmark target in the real world patients? Insights from BLITZ-4 Quality Campaign.

PubMed

Olivari, Zoran; Chinaglia, Alessandra; Gonzini, Lucio; Falsini, Giovanni; Pilleri, Annarita; Valente, Serafina; Gregori, Gianserafino; Rollo, Raffaele; My, Luigi; Scrimieri, Pietro; Lanzillo, Tonino; Corrado, Luigi; Chiti, Maurizio; Picardi, Elisa

2016-10-01

To define a benchmark target for an invasive strategy (IS) rate appropriate for performance assessment in intermediate-to-high risk non-ST-segment elevation acute coronary syndromes (NSTE-ACS). During the BLITZ-4 campaign, which aimed at improving the quality of care in 163 Italian coronary care units, 4923/5786 (85.1%) of consecutive patients admitted with NSTE-ACS with troponin elevation and/or dynamic ST-T changes on the electrocardiogram were managed with IS. The reasons driving the choice (RDC) for a conservative strategy (CS) in the remaining 863 patients were prospectively recorded. In 33.8%, CS was mandatory because of patients refusal, known coronary anatomy or death before coronary angiography; in 52.8% it was clinically justified because of active stroke, bleeding, advanced frailty, severe comorbidities, contraindication to antiplatelet therapy or because they were considered to be at low risk; only in 13.4% the reasons, such as renal failure, advanced age or other, were less stringent. As compared to patients undergoing IS, those in the CS were 12years older and had significantly more severe comorbidities. The in-hospital and 6-month all-cause mortality were 9.0% vs 0.9% and 22.0% vs 3.9% in CS and IS groups respectively (p<0.0001 for both). As the RDC for CS were clinically correct in vast majority of cases the observed 85% invasive strategy rate may be considered as the desirable benchmark target in patients with NSTE-ACS. For the same reason, it remains questionable if the higher rate of IS could have improved the prognosis in CS patients, despite their highly unfavorable prognosis. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

[Diamond-Forrester and cardiac CT : Is there a need to redefine the pretest probability of coronary artery disease?].

PubMed

Schuhbäck, A; Kolwelter, J; Achenbach, S

2016-08-01

Apart from the Diamond-Forrester classification, which is widely used particularly in the USA for the pretest probability of coronary artery disease, other scores also exist, such as an updated version of the classification table by Genders et al., the Morise score and the Duke clinical risk score. These scores estimate the probability of coronary artery disease, defined as the presence of at least one high-grade stenosis, based on symptom characteristics, age, gender and other parameters. All of the scores were derived from patient cohorts in which invasive coronary angiography had been performed for clinical reasons. It has subsequently been shown that these scores, especially those developed several decades ago, substantially overestimate the pretest probability of coronary artery disease. When these risk scores are applied to patients for whom a non-invasive work-up of suspected coronary artery disease is planned, for example by coronary computed tomography (CT) angiography, the expected prevalence of significant coronary stenosis will be overestimated. This, in turn, influences the test characteristics and the significance of the non-invasive examination (positive and negative predictive values) and needs to be taken into account when interpreting test results.

[Instantaneous wave-free ratio (iFR®) in patients with coronary artery disease].

PubMed

Baumann, S; Schaefer, A C; Hohneck, A; Mueller, K; Becher, T; Behnes, M; Renker, M; Borggrefe, M; Akin, I; Lossnitzer, D

2017-08-23

Coronary angiography is considered as the gold standard in the morphological representation of coronary artery stenosis. Coronary angiography is often performed without preprocedural non-invasive proof of ischemia and the assessment of the severity of a coronary lesion by morphology is very subjective. Thus, invasive fractional flow reserve (FFR) measurement represents the current standard for estimation of the hemodynamic relevance of coronary artery stenosis and facilitates decision making for percutaneous coronary intervention (PCI) and stenting. The FFR-guided revascularization strategy has been classified as a class IA recommendation in the 2014 ESC/EACTS guidelines on myocardial revascularization. Both the DEFER and the FAME studies showed no treatment advantage of hemodynamically irrelevant stenosis. By use of FFR (and targeted interventions), clinical results could be improved as well as the procedure costs were reduced; however, the use in clinical practice is still limited due to the need of adenosine administration and a significant prolongation of the procedure. Instantaneous wave-free ratio (iFR®) is a new innovative approach for the determination of the hemodynamic relevance of coronary stenosis which can be obtained at rest without the use of vasodilators. Regarding periprocedural complications as well as prognosis, iFR® showed non-inferiority compared to FFR in the SWEDEHEART and DEFINE-FLAIR trials.

The Collagen-Binding Protein Cnm Is Required for Streptococcus mutans Adherence to and Intracellular Invasion of Human Coronary Artery Endothelial Cells ▿

PubMed Central

Abranches, Jacqueline; Miller, James H.; Martinez, Alaina R.; Simpson-Haidaris, Patricia J.; Burne, Robert A.; Lemos, José A.

2011-01-01

Streptococcus mutans is considered the primary etiologic agent of dental caries, a global health problem that affects 60 to 90% of the population, and a leading causative agent of infective endocarditis. It can be divided into four different serotypes (c, e, f, and k), with serotype c strains being the most common in the oral cavity. In this study, we demonstrate that in addition to OMZ175 and B14, three other strains (NCTC11060, LM7, and OM50E) of the less prevalent serotypes e and f are able to invade primary human coronary artery endothelial cells (HCAEC). Invasive strains were also significantly more virulent than noninvasive strains in the Galleria mellonella (greater wax worm) model of systemic disease. Interestingly, the invasive strains carried an additional gene, cnm, which was previously shown to bind to collagen and laminin in vitro. Inactivation of cnm rendered the organisms unable to invade HCAEC and attenuated their virulence in G. mellonella. Notably, the cnm knockout strains did not adhere to HCAEC as efficiently as the parental strains did, indicating that the loss of the invasion phenotype observed for the mutants was linked to an adhesion defect. Comparisons of the invasive strains and their respective cnm mutants did not support a correlation between biofilm formation and invasion. Thus, Cnm is required for S. mutans invasion of endothelial cells and possibly represents an important virulence factor of S. mutans that may contribute to cardiovascular infections and pathologies. PMID:21422186

Anomalous Coronary Artery From the Opposite Sinus (ACAOS): Technical Challenges During Percutaneous Coronary Intervention.

PubMed

Sinha, Santosh Kumar; Razi, Mahmodula; Mahrotra, Anupam; Aggarwal, Puneet; Singh, Anupam; Rekwal, Lokendra; Tripathi, Sunil; Abhishekh, Nishant Kumar; Krishna, Vinay

2018-04-01

Anomalies of the coronary arteries are reported in 1-2% of patients among diagnostic angiogram. Ectopic origin of right coronary artery (RCA) from opposite sinus is one of the most common and they are mainly benign, but at times may be malignant. We report a case of a 69-year-old male who underwent early invasive percutaneous coronary intervention for non-ST-segment elevation myocardial infarction (NSTEMI) where RCA arising from left sinus at the root of left main artery was culprit and various technical challenges were encountered while intervening in form of cannulation to tracking of hardwares. RCA was cannulated with floating wire technique using hockey stick guide catheter and revascularized by deployment of 3.5 × 38 mm Promus Premier Everolimus eluting stent (Boston Scientific, USA). To the best of our knowledge, this is the first ever report of ectopic RCA being revascularized by using hockey stick catheter.

Usefulness of MRI to Differentiate Between Temporary and Long-Term Coronary Artery Occlusion in a Minimally Invasive Model of Experimental Myocardial Infarction

DOE Office of Scientific and Technical Information (OSTI.GOV)

Abegunewardene, Nico, E-mail: nico@uni-mainz.de; Vosseler, Markus; Gori, Tommaso

The surgical technique employed to determine an experimental ischemic damage is a major factor in the subsequent process of myocardial scar development. We set out to establish a minimally invasive porcine model of myocardial infarction using cardiac contrast-enhanced magnetic resonance imaging (ce-MRI) as the basic diagnostic tool. Twenty-seven domestic pigs were randomized to either temporary or permanent occlusion of the left anterior descending artery (LAD). Temporary occlusion was achieved by inflation of a percutaneous balloon in the left anterior descending artery directly beyond the second diagonal branch. Occlusion was maintained for 30 or 45 min, followed by reperfusion. Permanent occlusionmore » was achieved via thrombin injection. Thirteen animals died peri- or postinterventionally due to arrhythmias. Fourteen animals survived the 30-min ischemia (four animals; group 1), the 45-min ischemia (six animals; group 2), or the permanent occlusion (4 animals; group 3). Coronary angiography and ce-MRI were performed 8 weeks after coronary occlusion to document the coronary flow grade and the size of myocardial scar tissue. The LAD was patent in all animals in groups 1 and 2, with normal TIMI flow; in group 3 animals, the LAD was totally occluded. Fibrosis of the left ventricle in group 1 (4.9 {+-} 4.4%; p = 0.008) and group 2 (9.4 {+-} 2.9%; p = 0.05) was significantly lower than in group 3 (14.5 {+-} 3.9%). Wall thickness of the ischemic area was significantly lower in group 3 versus group 1 and group 2 (2.9 {+-} 0.3, 5.9 {+-} 0.7, and 6.1 {+-} 0.7 mm; p = 0.005). The extent of late enhancement of the left ventricle was also significantly higher in group 3 (16.9 {+-} 2.1%) compared to group 1 (5.3 {+-} 5.4%; p = 0.003) and group 2 (9.7 {+-} 3.4%, p = 0.013). In conclusion, the present model of minimally invasive infarction coupled with ce-MRI may represent a useful alternative to the open chest model for studies of myocardial infarction and scar development.« less

Vasomotor response of the human face: laser-Doppler measurements during mild hypo- and hyperthermia.

PubMed

Rasch, W; Cabanac, M

1993-04-01

The skin of the face is reputed not to vasoconstrict in response to cold stress because the face skin temperature remains steady during hypothermia. The purpose of the present work was to measure the vasomotor response of the human face to whole-body hypothermia, and to compare it with hyperthermia. Six male subjects were immersed in cold and in warm water to obtain the two conditions. Skin blood flow, evaporation, and skin temperature (Tsk) were recorded in three loci of the face, the forehead, the infra orbital area, and the cheek. Tympanic (Tty) and oesophageal (Toes) temperatures were also recorded during the different thermal states. Normothermic measurements served as control. Blood flow was recorded with a laser-Doppler flowmeter, evaporation measured with an evaporimeter. Face Tsk remained stable between normo-, hypo-, and hyperthermia. Facial blood flow, however, did not follow the same pattern. The facial blood flow remained at minimal vasoconstricted level when the subjects' condition was changed from normo- to hypothermia. When the condition changed from hypo- to hyperthermia a 3 to 9-fold increase in the blood flow was recorded. From these results it was concluded that a vasoconstriction seems to be the general vasomotor state in the face during normothermia.

Impact of coronary calcium score on the prevalence of coronary artery stenosis on dual source CT coronary angiography in caucasian patients with an intermediate risk.

PubMed

Meyer, Mathias; Henzler, Thomas; Fink, Christian; Vliegenthart, Rozemarijn; Barraza, J Michael; Nance, John W; Apfaltrer, Paul; Schoenberg, Stefan O; Wasser, Klaus

2012-11-01

To investigate the prevalence of significant coronary artery stenosis on coronary computed tomography angiography (cCTA) in symptomatic Caucasian patients with an intermediate risk score at different levels of coronary artery calcification (CAC). In total, 383 consecutive symptomatic Caucasian patients (147 females, 60 ± 13 years) with an intermediate risk score underwent nonenhanced CT for CAC scoring immediately before contrast-enhanced cCTA on a dual-source CT scanner. Additionally clinically indicated invasive coronary angiography (ICA) was performed in 90 patients. The prevalence of significant coronary artery stenosis (>50%) on cCTA and ICA was correlated at different CAC score levels. Of 121 patients with a zero CAC score, none had significant coronary artery stenosis on cCTA or ICA. Coronary CTA diagnosed in 54 of 70 patients with high CAC score (>400), a significant stenosis. Subsequent ICA confirmed significant stenosis in 30 of 32 patients. Sensitivity and a negative predictive value of CAC score ruling out significant stenosis on cCTA were 100% and 100%, respectively, using cutoff value of zero and specificity and positive predictive value to predict significant stenosis on cCTA were 79% and 51%, respectively, using a cutoff value of >400. Significant coronary artery stenosis is extremely unlikely, with an estimated risk of 4 in 1000 patients in symptomatic Caucasian patients with an intermediate risk score and negative CAC score. To reduce radiation exposure, radiation-free tests should be considered for differential diagnosis of chest pain in these patients. Copyright © 2012 AUR. Published by Elsevier Inc. All rights reserved.

Noninvasive coronary artery angiography using electron beam computed tomography

NASA Astrophysics Data System (ADS)

Rumberger, John A.; Rensing, Benno J.; Reed, Judd E.; Ritman, Erik L.; Sheedy, Patrick F., II

1996-04-01

Electron beam computed tomography (EBCT), also known as ultrafast-CT or cine-CT, uses a unique scanning architecture which allows for multiple high spatial resolution electrocardiographic triggered images of the beating heart. A recent study has demonstrated the feasibility of qualitative comparisons between EBCT derived 3D coronary angiograms and invasive angiography. Stenoses of the proximal portions of the left anterior descending and right coronary arteries were readily identified, but description of atherosclerotic narrowing in the left circumflex artery (and distal epicardial disease) was not possible with any degree of confidence. Although these preliminary studies support the notion that this approach has potential, the images overall were suboptimal for clinical application as an adjunct to invasive angiography. Furthermore, these studies did not examine different methods of EBCT scan acquisition, tomographic slice thicknesses, extent of scan overlap, or other segmentation, thresholding, and interpolation algorithms. Our laboratory has initiated investigation of these aspects and limitations of EBCT coronary angiography. Specific areas of research include defining effects of cardiac orientation; defining the effects of tomographic slice thickness and intensity (gradient) versus positional (shaped based) interpolation; and defining applicability of imaging each of the major epicardial coronary arteries for quantitative definition of vessel size, cross-sectional area, taper, and discrete vessel narrowing.

Assessment of vasoreactivity using videodensitometry coronary angiography.

PubMed

Molloi, Sabee; Berenji, Gholam R; Dang, Trien T; Kassab, Ghassan

2003-08-01

Previous studies demonstrated that the dysfunction of vasomotor tone (VT) is closely linked to the development of atherosclerosis and it is considered important in the very early stages of atherogenesis. Currently, the evaluation of VT relies on lumen changes in response to vasoactive stimuli using quantitative coronary angiography (QCA) based on geometric edge detection (ED). However, using ED for measuring lumen diameters is inherently associated with large uncertainties. Videodensitometry (VD) methods have important advantages over ED for QCA. The objective of this study was to investigate the reliability of VD and ED techniques in determining the effect of nitroglycerin (NTG) on cross-sectional area (CSA) and volume changes in a swine animal model for evaluating coronary vasoreactivity. Coronary angiography was performed on four anesthetized swine. CSA and volume were measured in the left anterior descending (LAD) coronary artery using VD before and after intracoronary injection of 0.3 mg of NTG. CSA was also calculated using standard QCA based on ED. The average CSA changes in the proximal, middle and distal branches measured using VD were 23.83% (+/-10.76%), 30.78% (+/-18.39%), and 27.34% (+/-36.53%), respectively. Similarly, the average CSA changes in the proximal, middle, and distal branches measured using ED were 15.02% (+/-36.38%), 22.02% (+/-26.12), and 38.00% (+/-48.31%), respectively. The average lumen volume change measured using VD was 29.79% (+/-14.79%). In order to evaluate the relative reliability of the techniques. the significance of deviation (SOD) was calculated, which is the ratio of the change after NTG and the measurement error. The average SOD for CSA for all the branches based on VD and ED were 1.86 and 0.69, respectively. The SOD for volume measurement was 2.78. Lumen changes measured by VD showed substantial improvement in reliability when compared to the ED. Moreover, VD can be used to measure substantially smaller changes in lumen

Diagnostic Value of Transthoracic Echocardiography in Patients With Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery

PubMed Central

Li, Rong-Juan; Sun, Zhonghua; Yang, Jiao; Yang, Ya; Li, Yi-Jia; Leng, Zhao-Ting; Liu, Guo-Wen; Pu, Li-Hong

2016-01-01

Abstract Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary abnormality associated with early infant mortality and sudden death in adults. Transthoracic echocardiography (TTE) plays an important role in early detection and diagnosis of ALCAPA as a noninvasive modality. However, its diagnostic value is not well studied. The purpose of this study is to determine the performance of TTE in the diagnostic assessment of ALCAPA as compared with coronary CT and invasive coronary angiography. A total of 22 patients (13 women and 9 men, mean age, 12.9 ± 19.5 years) with ALCAPA who underwent echocardiographic examination for clinical diagnosis were retrospectively reviewed and analyzed. Transthoracic echocardiographic features of ALCAPA were analyzed and its diagnostic value was compared with invasive coronary angiography and coronary CT angiography (CTA) with surgical findings serving as the gold standard. Surgery was performed in all of the patients to establish the dual coronary artery system. Five underwent the Takeuchi procedure and 17 had re-implantation of the anomalous left coronary artery. Of 20 patients, echocardiographic diagnoses were in good agreement with findings at surgery, resulting in the diagnostic accuracy of 90.9%. Two cases were misdiagnosed—one as the right coronary artery to pulmonary artery fistula and the other as rheumatic heart disease. The echocardiographic features of these patients with ALCAPA included: abnormal left coronary ostium arising from the pulmonary trunk with retrograde coronary artery flow in 20 patients; enlargement of the right coronary artery in 17 patients; abundant intercoronary septal collaterals in 17 patients; and moderate and significant mitral regurgitation in 14 patients. The diagnostic accuracy of invasive coronary angiography (in 17 patients) and coronary CTA (in 9 patients) was 100%. This study shows that TTE is an accurate, noninvasive imaging modality

Estimation of coronary wave intensity analysis using noninvasive techniques and its application to exercise physiology

PubMed Central

Nijjer, Sukhjinder; Sen, Sayan; Petraco, Ricardo; Jones, Siana; Al-Lamee, Rasha; Foin, Nicolas; Al-Bustami, Mahmud; Sethi, Amarjit; Kaprielian, Raffi; Ramrakha, Punit; Khan, Masood; Malik, Iqbal S.; Francis, Darrel P.; Parker, Kim; Hughes, Alun D.; Mikhail, Ghada W.; Mayet, Jamil; Davies, Justin E.

2015-01-01

Wave intensity analysis (WIA) has found particular applicability in the coronary circulation where it can quantify traveling waves that accelerate and decelerate blood flow. The most important wave for the regulation of flow is the backward-traveling decompression wave (BDW). Coronary WIA has hitherto always been calculated from invasive measures of pressure and flow. However, recently it has become feasible to obtain estimates of these waveforms noninvasively. In this study we set out to assess the agreement between invasive and noninvasive coronary WIA at rest and measure the effect of exercise. Twenty-two patients (mean age 60) with unobstructed coronaries underwent invasive WIA in the left anterior descending artery (LAD). Immediately afterwards, noninvasive LAD flow and pressure were recorded and WIA calculated from pulsed-wave Doppler coronary flow velocity and central blood pressure waveforms measured using a cuff-based technique. Nine of these patients underwent noninvasive coronary WIA assessment during exercise. A pattern of six waves were observed in both modalities. The BDW was similar between invasive and noninvasive measures [peak: 14.9 ± 7.8 vs. −13.8 ± 7.1 × 104 W·m−2·s−2, concordance correlation coefficient (CCC): 0.73, P < 0.01; cumulative: −64.4 ± 32.8 vs. −59.4 ± 34.2 × 102 W·m−2·s−1, CCC: 0.66, P < 0.01], but smaller waves were underestimated noninvasively. Increased left ventricular mass correlated with a decreased noninvasive BDW fraction (r = −0.48, P = 0.02). Exercise increased the BDW: at maximum exercise peak BDW was −47.0 ± 29.5 × 104 W·m−2·s−2 (P < 0.01 vs. rest) and cumulative BDW −19.2 ± 12.6 × 103 W·m−2·s−1 (P < 0.01 vs. rest). The BDW can be measured noninvasively with acceptable reliably potentially simplifying assessments and increasing the applicability of coronary WIA. PMID:26683900

Estimation of coronary wave intensity analysis using noninvasive techniques and its application to exercise physiology.

PubMed

Broyd, Christopher J; Nijjer, Sukhjinder; Sen, Sayan; Petraco, Ricardo; Jones, Siana; Al-Lamee, Rasha; Foin, Nicolas; Al-Bustami, Mahmud; Sethi, Amarjit; Kaprielian, Raffi; Ramrakha, Punit; Khan, Masood; Malik, Iqbal S; Francis, Darrel P; Parker, Kim; Hughes, Alun D; Mikhail, Ghada W; Mayet, Jamil; Davies, Justin E

2016-03-01

Wave intensity analysis (WIA) has found particular applicability in the coronary circulation where it can quantify traveling waves that accelerate and decelerate blood flow. The most important wave for the regulation of flow is the backward-traveling decompression wave (BDW). Coronary WIA has hitherto always been calculated from invasive measures of pressure and flow. However, recently it has become feasible to obtain estimates of these waveforms noninvasively. In this study we set out to assess the agreement between invasive and noninvasive coronary WIA at rest and measure the effect of exercise. Twenty-two patients (mean age 60) with unobstructed coronaries underwent invasive WIA in the left anterior descending artery (LAD). Immediately afterwards, noninvasive LAD flow and pressure were recorded and WIA calculated from pulsed-wave Doppler coronary flow velocity and central blood pressure waveforms measured using a cuff-based technique. Nine of these patients underwent noninvasive coronary WIA assessment during exercise. A pattern of six waves were observed in both modalities. The BDW was similar between invasive and noninvasive measures [peak: 14.9 ± 7.8 vs. -13.8 ± 7.1 × 10(4) W·m(-2)·s(-2), concordance correlation coefficient (CCC): 0.73, P < 0.01; cumulative: -64.4 ± 32.8 vs. -59.4 ± 34.2 × 10(2) W·m(-2)·s(-1), CCC: 0.66, P < 0.01], but smaller waves were underestimated noninvasively. Increased left ventricular mass correlated with a decreased noninvasive BDW fraction (r = -0.48, P = 0.02). Exercise increased the BDW: at maximum exercise peak BDW was -47.0 ± 29.5 × 10(4) W·m(-2)·s(-2) (P < 0.01 vs. rest) and cumulative BDW -19.2 ± 12.6 × 10(3) W·m(-2)·s(-1) (P < 0.01 vs. rest). The BDW can be measured noninvasively with acceptable reliably potentially simplifying assessments and increasing the applicability of coronary WIA. Copyright © 2016 the American Physiological Society.

Management and decision-making process leading to coronary angiography and revascularization in octogenarians with coronary artery disease: Insights from a large single-center registry.

PubMed

Martin, Anne-Céline; Dumas, Florence; Spaulding, Christian; Manzo-Silberman, Stéphane

2015-05-01

Cardiovascular diseases remain the most common cause of death in older adults. Guidelines state that advanced age alone should not limit the use of invasive therapy. However, coronary angiograms and subsequent revascularization are often not carried out in octogenarians. The benefit/risk balance of an invasive strategy and the decision-making process are not clearly defined. The aim of the present study was to assess the decision-making process, and the in-hospital and long-term mortality based on the clinical presentation, the diagnostic approach (coronary angiogram or conservative) and the therapeutic management (revascularization or not). The present study was a single-center retrospective analysis. A total of 522 patients aged ≥80 years, with a diagnosis of coronary disease were included from 2003 to 2009. The mean age was 82 ± 2.6 years. A total of 195 of 522 (37%) presented with a ST segment elevation myocardial infarction (STEMI). A coronary angiogram was carried out in 316 patients (60.5%) and 71% were treated by percutaneous coronary revascularization. A total of 39.5% were considered ineligible for a coronary angiogram due to cardiological reasons or comorbidities. Excluding cardiogenic shock, overall in-hospital mortality was 4.9%. Clinical presentation strongly influenced both in-hospital and 6-month mortality rates (cardiogenic shock 20% and 28.7%, stable angina 1% and 4.1%, respectively, P < 0.001). Long-term mortality was reduced in the coronary angiography arm compared with the conservative group (14.3% vs 20.9%, P = 0.04) whether or not revascularization was carried out. In the present study, in octogenarians, long-term mortality was lower in the group of patients who underwent a coronary angiogram, regardless of revascularization. The selection process for coronary angiography and angioplasty was mostly influenced by the existence of age-associated comorbidities. Risk prediction models are required to reduce age-dependent biases. �

Skin vasomotor hemiparesis followed by overactivity: characteristic thermography findings in a patient with Horner syndrome due to spinal cord infarction.

PubMed

Kobayashi, Makoto

2016-04-01

We present a 21-year-old female with Horner syndrome due to spinal cord infarction. In this patient, infrared thermography revealed a hemibody skin temperature increase followed by excessive focal decreases, indicating skin vasomotor hemiparesis and overactivity.

Software-based on-site estimation of fractional flow reserve using standard coronary CT angiography data.

PubMed

De Geer, Jakob; Sandstedt, Mårten; Björkholm, Anders; Alfredsson, Joakim; Janzon, Magnus; Engvall, Jan; Persson, Anders

2016-10-01

The significance of a coronary stenosis can be determined by measuring the fractional flow reserve (FFR) during invasive coronary angiography. Recently, methods have been developed which claim to be able to estimate FFR using image data from standard coronary computed tomography angiography (CCTA) exams. To evaluate the accuracy of non-invasively computed fractional flow reserve (cFFR) from CCTA. A total of 23 vessels in 21 patients who had undergone both CCTA and invasive angiography with FFR measurement were evaluated using a cFFR software prototype. The cFFR results were compared to the invasively obtained FFR values. Correlation was calculated using Spearman's rank correlation, and agreement using intraclass correlation coefficient (ICC). Sensitivity, specificity, accuracy, negative predictive value, and positive predictive value for significant stenosis (defined as both FFR ≤0.80 and FFR ≤0.75) were calculated. The mean cFFR value for the whole group was 0.81 and the corresponding mean invFFR value was 0.84. The cFFR sensitivity for significant stenosis (FFR ≤0.80/0.75) on a per-lesion basis was 0.83/0.80, specificity was 0.76/0.89, and accuracy 0.78/0.87. The positive predictive value was 0.56/0.67 and the negative predictive value was 0.93/0.94. The Spearman rank correlation coefficient was ρ = 0.77 (P < 0.001) and ICC = 0.73 (P < 0.001). This particular CCTA-based cFFR software prototype allows for a rapid, non-invasive on-site evaluation of cFFR. The results are encouraging and cFFR may in the future be of help in the triage to invasive coronary angiography. © The Foundation Acta Radiologica 2015.

Ten-year experience of an invasive cardiology centre with out-of-hospital cardiac arrest patients admitted for urgent coronary angiography.

PubMed

Zeliaś, Aleksander; Stępińska, Janina; Andres, Janusz; Trąbka-Zawicki, Aleksander; Sadowski, Jerzy; Żmudka, Krzysztof

2014-01-01

The aim of the study was to evaluate survival and neurological function of out-of-hospital cardiac arrest (OHCA) patients admitted for urgent coronary angiography (UCA) with a view to percutaneous coronary intervention (PCI). Hospital records of OHCA patients admitted to an invasive cardiology centre (providing 24 h a day/7 days a week service) in 2000-2010 were reviewed retrospectively, and similar data collected in 2011 were reviewed prospectively. Reports from the pre-hospital phase from emergency medical services (EMS) in Krakow were also analysed. Long-term follow-up data were collected by retrieving records from other hospitals (for patients transferred after UCA/PCI) and by phone calls to patients or their relatives. In 2000-2011, 405 OHCA patients were admitted for UCA/PCI. Most (78%) had ventricular fibrillation (VF) or ventricular tachycardia (VT) as the primary mechanism of cardiac arrest (asystole: 13%, pulseless electrical activity: 3%, unknown: 6%). The mean patient age was 61 (range 20-85) years, and 81% were males. On admission, about 70% of patients were unconscious and 11% were in cardiogenic shock. The mean resuscitation time (time to return of spontaneous circulation [ROSC]) was 26.7 (range 1-126) min. ST-T changes seen in an electrocardiogram recorded after ROSC included ST elevation and depression in 52% of cases, only ST depression in 21% of cases, only ST elevation in 17% of cases, unspecific changes (due to intraventricular conduction disturbances) in 7% of cases, negative T waves in 3% of cases, and no changes in 0.5% of cases. Coronary angiography revealed acute coronary occlusion in 48% of cases, critical coronary stenosis (> 90%) in 26% of cases, other significant coronary lesions (> 50% stenosis) in 15% of cases, and non-significant lesions in 11% of cases. An acute coronary syndrome (ACS) was diagnosed in 82% of patients (75% STEMI, 25% NSTEMI), and other cardiac cause (mostly ischaemic cardiomyopathy) was identified in 13% of

Left main coronary artery disease: pathophysiology, diagnosis, and treatment.

PubMed

Collet, Carlos; Capodanno, Davide; Onuma, Yoshinobu; Banning, Adrian; Stone, Gregg W; Taggart, David P; Sabik, Joseph; Serruys, Patrick W

2018-06-01

The advent of coronary angiography in the 1960s allowed for the risk stratification of patients with stable angina. Patients with unprotected left main coronary artery disease have an increased risk of death related to the large amount of myocardium supplied by this vessel. Although coronary angiography remains the preferred imaging modality for the evaluation of left main coronary artery stenosis, this technique has important limitations. Angiograms of the left main coronary artery segment can be difficult to interpret, and almost one-third of patients can be misclassified when fractional flow reserve is used as the reference. In patients with clinically significant unprotected left main coronary artery disease, surgical revascularization was shown to improve survival compared with medical therapy and has been regarded as the treatment of choice for unprotected left main coronary artery disease. Two large-scale clinical trials published in 2016 support the usefulness of catheter-based revascularization in selected patients with unprotected left main coronary artery disease. In this Review, we describe the pathophysiology of unprotected left main coronary artery disease, discuss diagnostic approaches in light of new noninvasive and invasive imaging techniques, and detail risk stratification models to aid the Heart Team in the decision-making process for determining the best revascularization strategy for these patients.

Coronary artery calcium score and CT angiography in asymptomatic elderly patients with high pretest probability for coronary artery disease.

PubMed

Imanzadeh, Amir; George, Elizabeth; Kondo, Takeshi; Takase, Shinichi; Amanuma, Makoto; Rybicki, Frank J; Kumamaru, Kanako K

2016-02-01

To evaluate the role of coronary artery calcium scoring (CACS) and/or coronary CT angiography (CCTA) in asymptomatic elderly patients with high pretest probability for coronary artery disease (CAD). Forty-eight consecutive asymptomatic elderly (>65 years) subjects who had a high pretest probability and underwent CACS/CCTA were included. Each CCTA was evaluated for adequacy for assessment of coronary stenosis. Significant stenosis (>50% diameter narrowing) was assessed on evaluable CT images and by invasive catheter angiography (ICA). All subjects were men with mean CACS of 880 ± 1779. Among those with low (0-99), intermediate (100-399), and high (400-999) CACS, ICA-verified significant stenosis was present in 8% (1/13), 23% (2/13), and 67% (8/12), respectively. Among those with very high CACS (≥ 1000) (n = 10), 90% of CCTAs were not evaluable for stenosis. In asymptomatic elderly subjects with high pretest probability, CACS followed by CCTA may be considered for those with intermediate to high CACS.

Postprandial triglyceride-rich lipoproteins promote invasion of human coronary artery smooth muscle cells in a fatty-acid manner through PI3k-Rac1-JNK signaling.

PubMed

Varela, Lourdes M; Bermúdez, Beatriz; Ortega-Gómez, Almudena; López, Sergio; Sánchez, Rosario; Villar, Jose; Anguille, Christelle; Muriana, Francisco J G; Roux, Pierre; Abia, Rocío

2014-06-01

The aim was to investigate the effect of postprandial triglyceride-rich lipoproteins (TRLs) with different fatty acid compositions on human coronary artery smooth muscle cell (hCASMC) invasion and to identify the molecular pathways involved. TRLs were isolated from the plasma of healthy volunteers after the ingestion of single meals enriched in MUFAs, saturated fatty acids (SFAs), or PUFAs. hCASMC invasion was analyzed using transwell chambers with Matrigel. TRLs-SFAs provoked the highest invasion, followed by TRLs-MUFAs and TRLs-PUFAs. Inhibition studies with Orlistat showed that invasion was dependent on the fatty acid composition of the TRLs. Fatty acids incorporated into the cell membranes strongly associated with cell invasion. Pull-down assays showed that TRLs-SFAs were able to increase Rac1 activity via inhibition of RhoA-dependent signaling. Chemical inhibition and siRNA studies showed that Rac1, PI3k, JNK, and MMP2 regulates TRL-SFA-induced hCASMC invasion. We demonstrate for the first time that TRLs induce hCASMCs invasion in a fatty acid dependent manner. This effect in TRLs-SFAs is mediated by the PI3k-Rac1-JNK, RhoA, and Rac1-MMP2 pathways. The ingestion of MUFA, compared to other dietary fatty acids such as SFA, could be considered as a nutritional strategy to reduce the atherosclerotic plaque formation. © 2014 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

The experience of totally endoscopic coronary bypass grafting with the robotic system «Da Vinci» in Russia

NASA Astrophysics Data System (ADS)

Efendiev, V. U.; Alsov, S. A.; Ruzmatov, T. M.; Mikheenko, I. L.; Chernyavsky, A. M.; Malakhov, E. S.

2015-11-01

A new technology - a thoracoscopic coronary bypass grafting with the use of Da Vinci robotic system in Russia is represented by the experience of NRICP. The technology was introduced in Russia in 2011. Overall, one hundred endoscopic coronary artery bypass procedures were performed. We have compared and analyzed results of coronary artery stenting vs minimally invasive coronary artery bypass grafting. According to the results, totally endoscopic coronary artery bypass grafting has several advantages over alternative treatment strategies.

Aerobic exercise for vasomotor menopausal symptoms: A cost-utility analysis based on the Active Women trial.

PubMed

Goranitis, Ilias; Bellanca, Leana; Daley, Amanda J; Thomas, Adele; Stokes-Lampard, Helen; Roalfe, Andrea K; Jowett, Sue

2017-01-01

To compare the cost-utility of two exercise interventions relative to a control group for vasomotor menopausal symptoms. Economic evaluation taking a UK National Health Service and Personal Social Services perspective and a societal perspective. Primary care. Peri- and postmenopausal women who have not used hormone therapy in the past 3 months and experience ≥ 5 episodes of vasomotor symptoms daily. An individual and a social support-based exercise intervention were evaluated. The former (Exercise-DVD), aimed to prompt exercise with purpose-designed DVD and written materials, whereas the latter (Exercise-Social support) with community exercise social support groups. Costs and outcomes associated with these interventions were compared to those of a control group, who could only have an exercise consultation. An incremental cost-utility analysis was undertaken using bootstrapping to account for the uncertainty around cost-effectiveness point-estimates. Cost per quality-adjusted life-year (QALY). Data for 261 women were available for analysis. Exercise-DVD was the most expensive and least effective intervention. Exercise-Social support was £52 (CIs: £18 to £86) and £18 (CIs: -£68 to £105) more expensive per woman than the control group at 6 and 12 months post-randomisation and led to 0.006 (CIs: -0.002 to 0.014) and 0.013 (CIs: -0.01 to 0.036) more QALYs, resulting in an incremental cost-effectiveness ratio of £8,940 and £1,413 per QALY gained respectively. Exercise-Social support had 80%-90% probability of being cost-effective in the UK context. A societal perspective of analysis and a complete-case analysis led to similar findings. Exercise-Social support resulted in a small gain in health-related quality of life at a marginal additional cost in a context where broader wellbeing and long-term gains associated with exercise and social participation were not captured. Community exercise social support groups are very likely to be cost-effective in the

Aerobic exercise for vasomotor menopausal symptoms: A cost-utility analysis based on the Active Women trial

PubMed Central

Goranitis, Ilias; Bellanca, Leana; Daley, Amanda J.; Thomas, Adele; Stokes-Lampard, Helen; Roalfe, Andrea K.

2017-01-01

Objective To compare the cost-utility of two exercise interventions relative to a control group for vasomotor menopausal symptoms. Design Economic evaluation taking a UK National Health Service and Personal Social Services perspective and a societal perspective. Setting Primary care. Population Peri- and postmenopausal women who have not used hormone therapy in the past 3 months and experience ≥ 5 episodes of vasomotor symptoms daily. Methods An individual and a social support-based exercise intervention were evaluated. The former (Exercise-DVD), aimed to prompt exercise with purpose-designed DVD and written materials, whereas the latter (Exercise-Social support) with community exercise social support groups. Costs and outcomes associated with these interventions were compared to those of a control group, who could only have an exercise consultation. An incremental cost-utility analysis was undertaken using bootstrapping to account for the uncertainty around cost-effectiveness point-estimates. Main outcome measure Cost per quality-adjusted life-year (QALY). Results Data for 261 women were available for analysis. Exercise-DVD was the most expensive and least effective intervention. Exercise-Social support was £52 (CIs: £18 to £86) and £18 (CIs: -£68 to £105) more expensive per woman than the control group at 6 and 12 months post-randomisation and led to 0.006 (CIs: -0.002 to 0.014) and 0.013 (CIs: -0.01 to 0.036) more QALYs, resulting in an incremental cost-effectiveness ratio of £8,940 and £1,413 per QALY gained respectively. Exercise-Social support had 80%-90% probability of being cost-effective in the UK context. A societal perspective of analysis and a complete-case analysis led to similar findings. Conclusions Exercise-Social support resulted in a small gain in health-related quality of life at a marginal additional cost in a context where broader wellbeing and long-term gains associated with exercise and social participation were not captured

Patient-specific coronary artery blood flow simulation using myocardial volume partitioning

NASA Astrophysics Data System (ADS)

Kim, Kyung Hwan; Kang, Dongwoo; Kang, Nahyup; Kim, Ji-Yeon; Lee, Hyong-Euk; Kim, James D. K.

2013-03-01

Using computational simulation, we can analyze cardiovascular disease in non-invasive and quantitative manners. More specifically, computational modeling and simulation technology has enabled us to analyze functional aspect such as blood flow, as well as anatomical aspect such as stenosis, from medical images without invasive measurements. Note that the simplest ways to perform blood flow simulation is to apply patient-specific coronary anatomy with other average-valued properties; in this case, however, such conditions cannot fully reflect accurate physiological properties of patients. To resolve this limitation, we present a new patient-specific coronary blood flow simulation method by myocardial volume partitioning considering artery/myocardium structural correspondence. We focus on that blood supply is closely related to the mass of each myocardial segment corresponding to the artery. Therefore, we applied this concept for setting-up simulation conditions in the way to consider many patient-specific features as possible from medical image: First, we segmented coronary arteries and myocardium separately from cardiac CT; then the myocardium is partitioned into multiple regions based on coronary vasculature. The myocardial mass and required blood mass for each artery are estimated by converting myocardial volume fraction. Finally, the required blood mass is used as boundary conditions for each artery outlet, with given average aortic blood flow rate and pressure. To show effectiveness of the proposed method, fractional flow reserve (FFR) by simulation using CT image has been compared with invasive FFR measurement of real patient data, and as a result, 77% of accuracy has been obtained.

Risks and Complications of Coronary Angiography: A Comprehensive Review

PubMed Central

Tavakol, Morteza; Ashraf, Salman; Brener, Sorin J.

2012-01-01

Coronary angiography and heart catheterization are invaluable tests for the detection and quantification of coronary artery disease, identification of valvular and other structural abnormalities, and measurement of hemodynamic parameters. The risks and complications associated with these procedures relate to the patient’s concomitant conditions and to the skill and judgment of the operator. In this review, we examine in detail the major complications associated with invasive cardiac procedures and provide the reader with a comprehensive bibliography for advanced reading. PMID:22980117

An investigation of correlation between left coronary bifurcation angle and hemodynamic changes in coronary stenosis by coronary computed tomography angiography-derived computational fluid dynamics

PubMed Central

Chaichana, Thanapong

2017-01-01

Background To investigate the correlation between left coronary bifurcation angle and coronary stenosis as assessed by coronary computed tomography angiography (CCTA)-generated computational fluid dynamics (CFD) analysis when compared to the CCTA analysis of coronary lumen stenosis and plaque lesion length with invasive coronary angiography (ICA) as the reference method. Methods Thirty patients (22 males, mean age: 59±6.9 years) with calcified plaques at the left coronary artery were included in the study with all patients undergoing CCTA and ICA examinations. CFD simulation was performed to analyze hemodynamic changes to the left coronary artery models in terms of wall shear stress, wall pressure and flow velocity, with findings correlated to the coronary stenosis and degree of bifurcation angle. Calcified plaque length was measured in the left coronary artery with diagnostic value compared to that from coronary lumen and bifurcation angle assessments. Results Of 26 significant stenosis at left anterior descending (LAD) and 13 at left circumflex (LCx) on CCTA, only 14 and 5 of them were confirmed to be >50% stenosis at LAD and LCx respectively on ICA, resulting in sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 100%, 52%, 49% and 100%. The mean plaque length was measured 5.3±3.6 and 4.4±1.9 mm at LAD and LCx, respectively, with diagnostic sensitivity, specificity, PPV and NPV being 92.8%, 46.7%, 61.9% and 87.5% for extensively calcified plaques. The mean bifurcation angle was measured 83.9±13.6º and 83.8±13.3º on CCTA and ICA, respectively, with no significant difference (P=0.98). The corresponding sensitivity, specificity, PPV and NPV were 100%, 78.6%, 84.2% and 100% based on bifurcation angle measurement on CCTA, 100%, 73.3%, 78.9% and 100% based on bifurcation angle measurements on ICA, respectively. Wall shear stress was noted to increase in the LAD and LCx models with significant stenosis and wider

Monocyte Chemoattractant Protein-1 as a Predictor of Coronary Atherosclerosis in Patients Receiving Coronary Angiography.

PubMed

Mahler, Simon A; Register, Thomas C; Riley, Robert F; D'Agostino, Ralph B; Stopyra, Jason P; Miller, Chadwick D

2018-06-01

Animal studies suggest that monocyte chemoattractant protein-1 (MCP-1) is a promising biomarker for coronary artery atherosclerosis (CAA), but human studies have been inconclusive. To determine potential relationships between plasma MCP-1 and CAA in patients with acute chest pain. A secondary analysis of 150 patients enrolled in emergency department chest pain risk stratification clinical investigations was conducted. Participants with stored blood and known coronary phenotypes (determined by coronary angiography) were selected using stratified randomization such that 50 patients were included into 3 groups: (1) no angiographic evidence of CAA, (2) nonobstructive CAA, and (3) obstructive CAA (stenosis ≥ 70%). Plasma MCP-1 levels were determined by enzyme-linked immunosorbent assay. The association between MCP-1 and obstructive CAA or any CAA was modeled using logistic regression. Variables in the unreduced model included age, sex, race, prior diagnosis of CAA or acute coronary syndrome, hyperlipidemia, hypertension, diabetes, smoking, and cardiac troponin I measurement. Among the 150 participants, 65.3% (98/150) had invasive coronary angiography and 34.7% (52/150) had coronary computed tomographic angiography. Myocardial infarction occurred in 27.3% (41/150) and coronary revascularization occurred in 26% (39/150) of the participants. Each 10 pg/mL increase in MCP-1 measurement was associated with an odds ratio of 1.12 (95% confidence interval, 1.06-1.19) for obstructive CAA. MCP-1 remained a significant predictor of obstructive CAA and any CAA after adjustment for age, sex, race, traditional cardiac risk factors, and cardiac troponin I. MCP-1 is independently associated with CAA among emergency department patients with chest pain.

Randomized trial comparing 600- with 300-mg loading dose of clopidogrel in patients with non-ST elevation acute coronary syndrome undergoing percutaneous coronary intervention: results of the Platelet Responsiveness to Aspirin and Clopidogrel and Troponin Increment after Coronary intervention in Acute coronary Lesions (PRACTICAL) Trial.

PubMed

Yong, Gerald; Rankin, Jamie; Ferguson, Louise; Thom, Jim; French, John; Brieger, David; Chew, Derek P; Dick, Ron; Eccleston, David; Hockings, Bernard; Walters, Darren; Whelan, Alan; Eikelboom, John W

2009-01-01

There is uncertainty about the benefit of a higher loading dose (LD) of clopidogrel in patients with non-ST elevation acute coronary syndrome (NSTEACS) undergoing early percutaneous coronary intervention (PCI). We compared the effects of a 600- versus a 300-mg LD of clopidogrel on inhibition of platelet aggregation, myonecrosis, and clinical outcomes in patients with NSTEACS undergoing an early invasive management strategy. Patients with NSTEACS (n = 256, mean age 63 years, 81.6% elevated troponin) without thienopyridine for at least 7 days were randomized to receive 600- or 300-mg LD of clopidogrel. Percutaneous coronary intervention was performed in 140 patients, with glycoprotein IIb/IIIa inhibitor use in 68.6%. Adenosine diphosphate (ADP)-induced platelet aggregation was measured by optical platelet aggregometry immediately before coronary angiography. Post-PCI myonecrosis was defined as a next-day troponin I greater than 5 times the upper limit of reference range and greater than baseline levels. Clopidogrel 600-mg LD compared with 300-mg LD was associated with significantly reduced ADP-induced platelet aggregation (49.7% vs 55.7% with ADP 20 micromol/L) but did not reduce post-PCI myonecrosis or adverse clinical outcomes to 6 months. There was no association between preprocedural platelet aggregation and outcome. These data confirm a modest incremental antiplatelet effect of a 600-mg clopidogrel LD compared with 300-mg LD but provide no support for a clinical benefit in patients with NSTEACS managed with an early invasive strategy including a high rate (69%) of glycoprotein IIb/IIIa inhibitor use during PCI.

Effect of Loading Dose of Atorvastatin Prior to Planned Percutaneous Coronary Intervention on Major Adverse Cardiovascular Events in Acute Coronary Syndrome: The SECURE-PCI Randomized Clinical Trial.

PubMed

Berwanger, Otavio; Santucci, Eliana Vieira; de Barros E Silva, Pedro Gabriel Melo; Jesuíno, Isabella de Andrade; Damiani, Lucas Petri; Barbosa, Lilian Mazza; Santos, Renato Hideo Nakagawa; Laranjeira, Ligia Nasi; Egydio, Flávia de Mattos; Borges de Oliveira, Juliana Aparecida; Dall Orto, Frederico Toledo Campo; Beraldo de Andrade, Pedro; Bienert, Igor Ribeiro de Castro; Bosso, Carlos Eduardo; Mangione, José Armando; Polanczyk, Carisi Anne; Sousa, Amanda Guerra de Moraes Rego; Kalil, Renato Abdala Karam; Santos, Luciano de Moura; Sposito, Andrei Carvalho; Rech, Rafael Luiz; Sousa, Antônio Carlos Sobral; Baldissera, Felipe; Nascimento, Bruno Ramos; Giraldez, Roberto Rocha Corrêa Veiga; Cavalcanti, Alexandre Biasi; Pereira, Sabrina Bernardez; Mattos, Luiz Alberto; Armaganijan, Luciana Vidal; Guimarães, Hélio Penna; Sousa, José Eduardo Moraes Rego; Alexander, John Hunter; Granger, Christopher Bull; Lopes, Renato Delascio

2018-04-03

The effects of loading doses of statins on clinical outcomes in patients with acute coronary syndrome (ACS) and planned invasive management remain uncertain. To determine if periprocedural loading doses of atorvastatin decrease 30-day major adverse cardiovascular events (MACE) in patients with ACS and planned invasive management. Multicenter, double-blind, placebo-controlled, randomized clinical trial conducted at 53 sites in Brazil among 4191 patients with ACS evaluated with coronary angiography to proceed with a percutaneous coronary intervention (PCI) if anatomically feasible. Enrollment occurred between April 18, 2012, and October 6, 2017. Final follow-up for 30-day outcomes was on November 6, 2017. Patients were randomized to receive 2 loading doses of 80 mg of atorvastatin (n = 2087) or matching placebo (n = 2104) before and 24 hours after a planned PCI. All patients received 40 mg of atorvastatin for 30 days starting 24 hours after the second dose of study medication. The primary outcome was MACE, defined as a composite of all-cause mortality, myocardial infarction, stroke, and unplanned coronary revascularization through 30 days. Among the 4191 patients (mean age, 61.8 [SD, 11.5] years; 1085 women [25.9%]) enrolled, 4163 (99.3%) completed 30-day follow-up. A total of 2710 (64.7%) underwent PCI, 333 (8%) underwent coronary artery bypass graft surgery, and 1144 (27.3%) had exclusively medical management. At 30 days, 130 patients in the atorvastatin group (6.2%) and 149 in the placebo group (7.1%) had a MACE (absolute difference, 0.85% [95% CI, -0.70% to 2.41%]; hazard ratio, 0.88; 95% CI, 0.69-1.11; P = .27). No cases of hepatic failure were reported; 3 cases of rhabdomyolysis were reported in the placebo group (0.1%) and 0 in the atorvastatin group. Among patients with ACS and planned invasive management with PCI, periprocedural loading doses of atorvastatin did not reduce the rate of MACE at 30 days. These findings do not support the routine use

Impact of vasomotion type on prognosis of coronary artery spasm induced by acetylcholine provocation test of left coronary artery.

PubMed

Lee, Eun Mi; Choi, Man Ho; Seo, Hong Seog; Kim, Hyun Ki; Kim, Nam-Ho; Choi, Cheol Ung; Kim, Jin Won; Lim, Hong Euy; Kim, Eung Ju; Rha, Seung-Woon; Park, Chang Gyu; Oh, Dong Joo

2017-02-01

The impact of vasomotion types on long-term clinical outcomes in patients with coronary artery spasm (CAS) induced by the acetylcholine provocation test (ACH-test) remains unclear. We evaluated 4644 consecutive patients with typical resting chest pain (CP), but no angiographically significant coronary artery lesion (<50% stenosis), who underwent an ACH-test. According to their vasomotor response, patients were categorized into four types: normal vasomotion (no CP, no ischemic electrocardiographic changes, and no vasoconstriction), microvascular spasm (CP with <75% vasoconstriction but with CP relief after nitroglycerin infusion), epicardial spasm (CP with ≥75% vasoconstriction), and ACH-test inconclusive (vasoconstriction and/or electrocardiographic changes, but no CP). We investigated CP recurrence requiring follow-up angiography and major adverse cardiovascular events (MACEs) during 5 years. CP recurred in 7.9% of patients and was more frequent in abnormal vasomotion types (normal vasomotion, microvascular spasm, epicardial spasm, and inconclusive type: 5.4%, 9.8%, 10.9%, and 8.2%, respectively, log-rank p = 0.009). In multivariate analysis adjusted for medication use after the ACH-test, vasomotion subtype was not an independent predictor, whereas male sex, fixed lesion on baseline angiography, and medications including calcium channel blockers (CCBs), nitrates, and statins were independent positive predictors for recurrent CP. Alcohol consumption at the initial interview was a negative predictor. MACEs were observed in 1.6%, and the incidence was similar among subtypes (p = 0.421). Recurrent CP and long-term outcomes are independent of vasomotion subtypes, but long-term use of CCBs, nitrates, and statins is a significant predictor for recurrent CP. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

High-fat diet-induced obesity leads to increased NO sensitivity of rat coronary arterioles: role of soluble guanylate cyclase activation.

PubMed

Jebelovszki, Eva; Kiraly, Csaba; Erdei, Nora; Feher, Attila; Pasztor, Eniko T; Rutkai, Ibolya; Forster, Tamas; Edes, Istvan; Koller, Akos; Bagi, Zsolt

2008-06-01

The impact of obesity on nitric oxide (NO)-mediated coronary microvascular responses is poorly understood. Thus NO-mediated vasomotor responses were investigated in pressurized coronary arterioles ( approximately 100 microm) isolated from lean (on normal diet) and obese (fed with 60% of saturated fat) rats. We found that dilations to acetylcholine (ACh) were not significantly different in obese and lean rats (lean, 83 +/- 4%; and obese, 85 +/- 3% at 1 microM), yet the inhibition of NO synthesis with N(omega)-nitro-l-arginine methyl ester reduced ACh-induced dilations only in vessels of lean controls. The presence of the soluble guanylate cyclase (sGC) inhibitor oxadiazolo-quinoxaline (ODQ) elicited a similar reduction in ACh-induced dilations in the two groups of vessels (lean, 60 +/- 11%; and obese, 57 +/- 3%). Dilations to NO donors, sodium nitroprusside (SNP), and diethylenetriamine (DETA)-NONOate were enhanced in coronary arterioles of obese compared with lean control rats (lean, 63 +/- 6% and 51 +/- 5%; and obese, 78 +/- 5% and 70 +/- 5%, respectively, at 1 microM), whereas dilations to 8-bromo-cGMP were not different in the two groups. In the presence of ODQ, both SNP and DETA-NONOate-induced dilations were reduced to a similar level in lean and obese rats. Moreover, SNP-stimulated cGMP immunoreactivity in coronary arterioles and also cGMP levels in carotid arteries were enhanced in obese rats, whereas the protein expression of endothelial NOS and the sGC beta1-subunit were not different in the two groups. Collectively, these findings suggest that in coronary arterioles of obese rats, the increased activity of sGC leads to an enhanced sensitivity to NO, which may contribute to the maintenance of NO-mediated dilations and coronary perfusion in obesity.

Comparison of different models for non-invasive FFR estimation

NASA Astrophysics Data System (ADS)

Mirramezani, Mehran; Shadden, Shawn

2017-11-01

Coronary artery disease is a leading cause of death worldwide. Fractional flow reserve (FFR), derived from invasively measuring the pressure drop across a stenosis, is considered the gold standard to diagnose disease severity and need for treatment. Non-invasive estimation of FFR has gained recent attention for its potential to reduce patient risk and procedural cost versus invasive FFR measurement. Non-invasive FFR can be obtained by using image-based computational fluid dynamics to simulate blood flow and pressure in a patient-specific coronary model. However, 3D simulations require extensive effort for model construction and numerical computation, which limits their routine use. In this study we compare (ordered by increasing computational cost/complexity): reduced-order algebraic models of pressure drop across a stenosis; 1D, 2D (multiring) and 3D CFD models; as well as 3D FSI for the computation of FFR in idealized and patient-specific stenosis geometries. We demonstrate the ability of an appropriate reduced order algebraic model to closely predict FFR when compared to FFR from a full 3D simulation. This work was supported by the NIH, Grant No. R01-HL103419.

Self-expanding stent for spontaneous coronary artery dissection: a rational choice.

PubMed

Mele, Marco; Langialonga, Tommaso; Maggi, Alessandro; Villella, Massimo; Villella, Alessandro

2016-12-01

: Spontaneous coronary artery dissection (SCAD) is a rare and poorly understood cause of acute coronary syndrome in relatively young patients. Nowadays, the optimal treatment of SCAD is uncertain. A conservative approach seems to be preferable, but in particular conditions, an invasive strategy is necessary. The poor rate of procedural success, the high risk of procedural complications and the uncertain long and mid-term results make the interventional treatment of SCAD a challenge. We report a case of a young male patient presenting with SCAD successfully treated with a sirolimus-eluting self-expanding coronary stent. To our knowledge, the use of self-expanding coronary stent for SCAD has never been described yet and we discuss about the rationale of a possible larger use in clinical practice.

Impact of minimally invasive surgery on medical spending and employee absenteeism.

PubMed

Epstein, Andrew J; Groeneveld, Peter W; Harhay, Michael O; Yang, Feifei; Polsky, Daniel

2013-07-01

As many surgical procedures have undergone a transition from a standard, open surgical approach to a minimally invasive one in the past 2 decades, the diffusion of minimally invasive surgery may have had sizeable but overlooked effects on medical expenditures and worker productivity. To examine the impact of standard vs minimally invasive surgery on health plan spending and workplace absenteeism for 6 types of surgery. Cross-sectional regression analysis. National health insurance claims data and matched workplace absenteeism data from January 1, 2000, to December 31, 2009. A convenience sample of adults with employer-sponsored health insurance who underwent either standard or minimally invasive surgery for coronary revascularization, uterine fibroid resection, prostatectomy, peripheral revascularization, carotid revascularization, or aortic aneurysm repair. Health plan spending and workplace absenteeism from 14 days before through 352 days after the index surgery. There were 321,956 patients who underwent surgery; 23,814 were employees with workplace absenteeism data. After multivariable adjustment, mean health plan spending was lower for minimally invasive surgery for coronary revascularization (-$30,850; 95% CI, -$31,629 to -$30,091), uterine fibroid resection (-$1509; 95% CI, -$1754 to -$1280), and peripheral revascularization (-$12,031; 95% CI, -$15,552 to -$8717) and higher for prostatectomy ($1350; 95% CI, $611 to $2212) and carotid revascularization ($4900; 95% CI, $1772 to $8370). Undergoing minimally invasive surgery was associated with missing significantly fewer days of work for coronary revascularization (mean difference, -37.7 days; 95% CI, -41.1 to -34.3), uterine fibroid resection (mean difference, -11.7 days; 95% CI, -14.0 to -9.4), prostatectomy (mean difference, -9.0 days; 95% CI, -14.2 to -3.7), and peripheral revascularization (mean difference, -16.6 days; 95% CI, -28.0 to -5.2). For 3 of 6 types of surgery studied, minimally invasive

Coronary involvement in Churg-Strauss syndrome.

PubMed

Dendramis, Gregory; Paleologo, Claudia; Piraino, Davide; Arrotti, Salvatore; Assennato, Pasquale

2015-01-01

Systemic autoimmune diseases are themselves a relevant and independent risk factor for atherosclerosis and coronary ectasia. We describe a case of a 58-year-old Caucasian man who was admitted to our department for unstable angina. History of asthma, paranasal sinus abnormality, and peripheral eosinophilia given a high suspicion of Churg-Strauss syndrome (CSS). Diagnosis was performed with 5 of the 6 American College of Rheumatology criteria. The knowledge that CSS is often associated with significant coronary artery involvement and the persistence of chest pain led us to performing immediately a coronary angiography. Coronary angiography showed diffuse ectasic lesions, chronic occlusion of left anterior descending artery with homocoronary collateral circulation from left circumflex artery and subocclusive stenosis in the proximal tract of posterior descending artery. The early recognition of CSS, an aggressive invasive diagnostic approach, and an early appropriate therapy are important to prevent the progressive and permanent cardiac damage in these patients. In the setting of a multidisciplinary approach, careful cardiac assessment is an essential step in CSS, even in mildly symptomatic patients. Copyright © 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

Non-Acute Coronary Syndrome Anginal Chest Pain

PubMed Central

Agarwal, Megha; Mehta, Puja K.; Merz, C. Noel Bairey

2010-01-01

Anginal chest pain is one of the most common complaints in the outpatient setting. While much of the focus has been on identifying obstructive atherosclerotic coronary artery disease (CAD) as the cause of anginal chest pain, it is clear that microvascular coronary dysfunction (MCD) can also cause anginal chest pain as a manifestation of ischemic heart disease (IHD), and carries an increased cardiovascular risk. Epicardial coronary vasospasm, aortic stenosis, left ventricular hypertrophy, congenital coronary anomalies, mitral valve prolapse and abnormal cardiac nociception can also present as angina of cardiac origin. For non-acute coronary syndrome (ACS) stable chest pain, exercise treadmill testing (ETT) remains the primary tool for diagnosis of ischemia and cardiac risk stratification; however, in certain subsets of patients, such as women, ETT has a lower sensitivity and specificity for identifying obstructive CAD. When combined with an imaging modality, such as nuclear perfusion or echocardiography testing, the sensitivity and specificity of stress testing for detection of obstructive CAD improves significantly. Advancements in stress cardiac magnetic resonance imaging (MRI) enables detection of perfusion abnormalities in a specific coronary artery territory, as well as subendocardial ischemia associated with MCD. Coronary computed tomography angiography (CCTA) enables visual assessment of obstructive CAD, albeit with a higher radiation dose. Invasive coronary angiography (CA) remains the gold standard for diagnosis and treatment of obstructive lesions that cause medically refractory stable angina. Furthermore, in patients with normal coronary angiograms, the addition of coronary reactivity testing (CRT) can help diagnose endothelial dependent and independent microvascular dysfunction. Life-style modification and pharmacologic intervention remains the cornerstone of therapy to reduce morbidity and mortality in patients with stable angina. This review focuses on

Spontaneous Coronary Dissection: "Live Flash" Optical Coherence Tomography Guided Angioplasty.

PubMed

Bento, Angela Pimenta; Fernandes, Renato Gil Dos Santos Pinto; Neves, David Cintra Henriques Silva; Patrício, Lino Manuel Ribeiro; de Aguiar, José Eduardo Chambel

2016-01-01

Optical Coherence tomography (OCT) is a light-based imaging modality which shows tremendous potential in the setting of coronary imaging. Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome (ACS). The diagnosis of SCAD is made mainly with invasive coronary angiography, although adjunctive imaging modalities such as computed tomography angiography, IVUS, and OCT may increase the diagnostic yield. The authors describe a clinical case of a young woman admitted with the diagnosis of ACS. The ACS was caused by SCAD detected in the coronary angiography and the angioplasty was guided by OCT. OCT use in the setting of SCAD has been already described and the true innovation in this case was this unique use of OCT. The guidance of angioplasty with live and short images was very useful as it allowed clearly identifying the position of the guidewires at any given moment without the use of prohibitive amounts of contrast.

Design and rationale of the MR-INFORM study: stress perfusion cardiovascular magnetic resonance imaging to guide the management of patients with stable coronary artery disease.

PubMed

Hussain, Shazia T; Paul, Matthias; Plein, Sven; McCann, Gerry P; Shah, Ajay M; Marber, Michael S; Chiribiri, Amedeo; Morton, Geraint; Redwood, Simon; MacCarthy, Philip; Schuster, Andreas; Ishida, Masaki; Westwood, Mark A; Perera, Divaka; Nagel, Eike

2012-09-19

In patients with stable coronary artery disease (CAD), decisions regarding revascularisation are primarily driven by the severity and extent of coronary luminal stenoses as determined by invasive coronary angiography. More recently, revascularisation decisions based on invasive fractional flow reserve (FFR) have shown improved event free survival. Cardiovascular magnetic resonance (CMR) perfusion imaging has been shown to be non-inferior to nuclear perfusion imaging in a multi-centre setting and superior in a single centre trial. In addition, it is similar to invasively determined FFR and therefore has the potential to become the non-invasive test of choice to determine need for revascularisation. The MR-INFORM study is a prospective, multi-centre, randomised controlled non-inferiority, outcome trial. The objective is to compare the efficacy of two investigative strategies for the management of patients with suspected CAD. Patients presenting with stable angina are randomised into two groups: 1) The FFR-INFORMED group has subsequent management decisions guided by coronary angiography and fractional flow reserve measurements. 2) The MR-INFORMED group has decisions guided by stress perfusion CMR. The primary end-point will be the occurrence of major adverse cardiac events (death, myocardial infarction and repeat revascularisation) at one year. Clinical trials.gov identifier NCT01236807. MR INFORM will assess whether an initial strategy of CMR perfusion is non-inferior to invasive angiography supplemented by FFR measurements to guide the management of patients with stable coronary artery disease. Non-inferiority of CMR perfusion imaging to the current invasive reference standard (FFR) would establish CMR perfusion imaging as an attractive non-invasive alternative to current diagnostic pathways.

Ethnic differences in invasive management of coronary disease: prospective cohort study of patients undergoing angiography

PubMed Central

Feder, Gene; Crook, Angela M; Magee, Patrick; Banerjee, Shrilla; Timmis, Adam D; Hemingway, Harry

2002-01-01

Objectives To compare rates of revascularisation in south Asian and white patients undergoing coronary angiography in relation to the appropriateness of revascularisation and clinical outcome. Design Prospective cohort study of patients with two and a half years' follow up; appropriateness of revascularisation rated by nine experts with no knowledge of ethnicity of patient. Setting Tertiary cardiac centre in London with referral from five contiguous health authorities. Participants Consecutive patients (502 south Asian, 2974 white) undergoing coronary angiography in the appropriateness of coronary revascularisation study (ACRE). Main outcome measures Coronary revascularisation, non-fatal myocardial infarction, mortality. Results There was no difference between south Asian and white patients in the proportions deemed appropriate for revascularisation (72% (361) v 68% (2022)) or in the proportions for whom the physician's intended management was revascularisation (39% (196) v 41% (1218)). Among patients appropriate for revascularisation, age adjusted rates of coronary angioplasty (hazard ratio 0.69, 95% confidence interval 0.47 to 1.00, P=0.058) and coronary artery bypass grafting (0.74, 0.58 to 0.91, P=0.007) were lower in south Asian than in white patients. These differences were smaller but still present after adjustment for socioeconomic status and after restriction of analysis to those patients for whom the intended management was revascularisation. There were no differences in mortality and non-fatal myocardial infarction between south Asian and white patients (1.07, 0.78 to 1.47). Conclusion Among patients deemed appropriate for coronary artery bypass grafting, south Asian patients are less likely than white patients to receive it. This difference is not explained by physician bias. What is already known on this topicUS studies have shown inequity in use of cardiac revascularisation procedures between white patients and African-AmericansStudies in England

[Management of coronary artery disease at the acute phase].

PubMed

Chatot, Marion; Schiele, François

2015-03-01

In patients with acute coronary syndrome (ACS), early management is of prime importance. However, the median time taken by the patient to call the emergency services is often very long, up to 2 hours. The presence of a physician as first responder ensures good quality resuscitation in case of cardiac arrest, and allows recording of a first ECG, which can be very informative, especially in ACS without ST segment elevation. Treatment at this stage is limited to sublingual nitroglycerin and aspirin. If the first ECG shows ST segment elevation, the patient should be immediately oriented for reperfusion, usually by percutaneous coronary intervention. in the absence of ST segment elevation, the diagnosis of ACS remains unconfirmed. This does not imply that the risk is lesser, but rather that the risk cannot be evaluated accurately in the pre-hospital setting. The use of risk scores can guide the choice of management towards an invasive strategy, including coronary angiography (immediately, or within 24-72 hours). Low-risk patients are candidates for an invasive strategy, provided non-invasive tests demonstrate the presence of ischemia. During the hospital phase, antiplatelet treatment should be initiated and must be adapted to the patient bleeding and thrombotic risk. Clopidogrel is recommended only in patients who are not amenable to prasugrel or ticagrelor. Statin therapy should be initiated from day one, regardless of the initial cholesterol level, preferably with 80 mg atorvastatin. Angiotensin-converting enzyme inhibitors and beta-blockers should also be prescribed to complete the medical prescription both in-hospital and in the long term.

[Coronary artery disease and cardiac ischemic disease: two different pathologies with different diagnostic procedures].

PubMed

Vallejo, Enrique

2009-01-01

Coronary artery disease (CAD) remains the leading cause of death in the Western world, and early detection of CAD allows optimal therapeutic management. The gold standard has always been invasive coronary angiography, but over the years various non-invasive techniques have been developed to detect CAD, including cardiac SPECT and cardiac computed tomography (Cardiac CT). Cardiac SPECT permitted visualization of myocardial perfusion and have focused on the assessment of the hemodynamic consequences of obstructive coronary lesions as a marker of CAD. Cardiac CT focuses on the detection of atherosclerosis rather than ischemia, and permit detection of CAD at an earlier stage. Objectives of this manuscript are to discuss the clinical experience with both modalities and to provide a critical review of the strengths and limitations of Cardiac SPECT and Cardiac CT for the diagnostic and management of patients with suspected CAD or cardiac ischemic disease.

Coronary artery anomalies overview: The normal and the abnormal

PubMed Central

Villa, Adriana DM; Sammut, Eva; Nair, Arjun; Rajani, Ronak; Bonamini, Rodolfo; Chiribiri, Amedeo

2016-01-01

The aim of this review is to give a comprehensive and concise overview of coronary embryology and normal coronary anatomy, describe common variants of normal and summarize typical patterns of anomalous coronary artery anatomy. Extensive iconography supports the text, with particular attention to images obtained in vivo using non-invasive imaging. We have divided this article into three groups, according to their frequency in the general population: Normal, normal variant and anomaly. Although congenital coronary artery anomalies are relatively uncommon, they are the second most common cause of sudden cardiac death among young athletes and therefore warrant detailed review. Based on the functional relevance of each abnormality, coronary artery anomalies can be classified as anomalies with obligatory ischemia, without ischemia or with exceptional ischemia. The clinical symptoms may include chest pain, dyspnea, palpitations, syncope, cardiomyopathy, arrhythmia, myocardial infarction and sudden cardiac death. Moreover, it is important to also identify variants and anomalies without clinical relevance in their own right as complications during surgery or angioplasty can occur. PMID:27358682

Coronary Computed Tomography Angiography vs Functional Stress Testing for Patients With Suspected Coronary Artery Disease: A Systematic Review and Meta-analysis.

PubMed

Foy, Andrew J; Dhruva, Sanket S; Peterson, Brandon; Mandrola, John M; Morgan, Daniel J; Redberg, Rita F

2017-11-01

Coronary computed tomography angiography (CCTA) is a new approach for the diagnosis of anatomical coronary artery disease (CAD), but it is unclear how CCTA performs compared with the standard approach of functional stress testing. To compare the clinical effectiveness of CCTA with that of functional stress testing for patients with suspected CAD. A systematic literature search was conducted in PubMed and MEDLINE for English-language randomized clinical trials of CCTA published from January 1, 2000, to July 10, 2016. Researchers selected randomized clinical trials that compared a primary strategy of CCTA with that of functional stress testing for patients with suspected CAD and reported data on patient clinical events and changes in therapy. Two reviewers independently extracted data from and assessed the quality of the trials. This analysis followed the PRISMA statement for reporting systematic reviews and meta-analyses and used the Cochrane Collaboration's tool for assessing risk of bias in randomized trials. The Mantel-Haenszel method was used to conduct the primary analysis. Summary relative risks were calculated with a random-effects model. The outcomes of interest were all-cause mortality, cardiac hospitalization, myocardial infarction, invasive coronary angiography, coronary revascularization, new CAD diagnoses, and change in prescription for aspirin and statins. Thirteen trials were included, with 10 315 patients in the CCTA arm and 9777 patients in the functional stress testing arm who were followed up for a mean duration of 18 months. There were no statistically significant differences between CCTA and functional stress testing in death (1.0% vs 1.1%; risk ratio [RR], 0.93; 95% CI, 0.71-1.21) or cardiac hospitalization (2.7% vs 2.7%; RR, 0.98; 95% CI, 0.79-1.21), but CCTA was associated with a reduction in the incidence of myocardial infarction (0.7% vs 1.1%; RR, 0.71; 95% CI, 0.53-0.96). Patients undergoing CCTA were significantly more likely to undergo

Kawasaki disease and giant coronary artery aneurysms: the role of echocardiography from diagnosis through follow-up.

PubMed

Adler, Adam C; Kodavatiganti, Ramesh

2016-08-01

Kawasaki disease is an acquired vasculitis that can affect the coronary arteries placing the patient at risk for coronary artery thrombosis, myocardial ischemia and infarction. The risk of complications related to coronary artery involvement persists for years despite recovery from the acute illness phase. The risk of late coronary disease progression necessitates long term follow-up generally accomplished by non-invasive echocardiography in pediatric patients. We review the utility of echocardiography in patients with Kawasaki disease as it relates to initial management, risk stratification and follow-up of these children. © 2016, Wiley Periodicals, Inc.

Multicenter Evaluation Of Coronary Dual-Source CT angiography in patients with intermediate Risk of Coronary Artery Stenoses (MEDIC): study design and rationale.

PubMed

Marwan, Mohamed; Hausleiter, Jörg; Abbara, Suhny; Hoffmann, Udo; Becker, Christoph; Ovrehus, Kristian; Ropers, Dieter; Bathina, Ravi; Berman, Dan; Anders, Katharina; Uder, Michael; Meave, Aloha; Alexánderson, Erick; Achenbach, Stephan

2014-01-01

The diagnostic performance of multidetector row CT to detect coronary artery stenosis has been evaluated in numerous single-center studies, with only limited data from large cohorts with low-to-intermediate likelihood of coronary disease and in multicenter trials. The Multicenter Evaluation of Coronary Dual-Source CT Angiography in Patients with Intermediate Risk of Coronary Artery Stenoses (MEDIC) trial determines the accuracy of dual-source CT (DSCT) to identify persons with at least 1 coronary artery stenosis among patients with low-to-intermediate pretest likelihood of disease. The MEDIC trial was designed as a prospective, multicenter, international trial to evaluate the diagnostic performance of DSCT for the detection of coronary artery stenosis compared with invasive coronary angiography. The study includes 8 sites in Germany, India, Mexico, the United States, and Denmark. The study population comprises patients referred for a diagnostic coronary angiogram because of suspected coronary artery disease with an intermediate pretest likelihood as determined by sex, age, and symptoms. All evaluations are performed by blinded core laboratory readers. The primary outcome of the MEDIC trial is the accuracy of DSCT to identify the presence of coronary artery stenoses with a luminal diameter narrowing of 50% or more on a per-vessel basis. Secondary outcome parameters include per-patient and per-segment diagnostic accuracy for 50% stenoses and accuracy to identify stenoses of 70% or more. Furthermore, secondary outcome parameters include the influence of heart rate, Agatston score, body weight, body mass index, image quality, and diagnostic confidence on the accuracy to detect coronary artery stenoses >50% on a per-vessel basis. The results of the MEDIC trial will assess the clinical utility of coronary CT angiography in the evaluation of patients with intermediate pretest likelihood of coronary artery disease. Copyright © 2014 Society of Cardiovascular Computed

Pledget Induced Cardiogenic Shock Following a Minimally Invasive Aortic Valve Replacement.

PubMed

Tedesco, Alexandra E; Tedesco, Victor E

2017-01-01

Within the last decade, minimally invasive valve replacements have become exceedingly popular, and as a result, so has the rise of technology aimed at refining and simplifying these techniques. With new technology, new complications are inevitable. We present a routine Minimally invasive aortic valve replacement through a right anterior minithoracotomy complicated by pledget impaction in a coronary artery.

Coronary In-Stent Restenosis: Assessment with Corrected Coronary Opacification Difference across Coronary Stents Measured with CT Angiography.

PubMed

Gao, Yang; Lu, Bin; Hou, Zhi Hui; Yu, Fang Fang; Yin, Wei Hua; Wang, Zhi Qiang; Wu, Yong Jian; Mu, Chao Wei; Meinel, Felix G; McQuiston, Andrew D; Schoepf, U Joseph

2015-05-01

To determine whether changes in coronary opacification normalized to the aorta (corrected coronary opacification [CCO]) across stents can help identify in-stent restenosis (ISR) severity with use of invasive coronary angiography as the standard of reference. This study was approved by the institutional review board, and the requirement to obtain informed consent was waived. The authors retrospectively analyzed 106 patients (88 men, 18 women; mean age, 59.6 years ± 10.4; age range, 36-84 years) who had previously undergone stent implantation within 3 months of coronary computed tomographic (CT) angiography. Attenuation values in the coronary lumen were measured proximal and distal to the stents and normalized to the descending aorta. The CCO difference across the stent was compared with the severity of ISR. One-way analysis of variance least significant difference was used for comparison. A total of 141 stents were assessed. Seventy-six stents were normally patent, 18 had ISR of less than 50%, 28 had ISR of 50%-99%, and 19 were fully occluded. The median CCO differences in the four groups were 0.078, 0.163, 0.346, and 0.606, respectively. There was no significant difference between stents with an ISR of at least 50% and those with total occlusion (P = .056), although the other groups had significant differences at pairwise comparison (P < .01 for all). For stents smaller than 3 mm in diameter, the median CCO differences in the four groups were 0.086, 0.136, 0.390, and 0.471, respectively. The CCO differences across normal stents and stents with ISR of less than 50% were significantly less than those across stents with an ISR of at least 50% and those with total occlusion (P < .01 for all). There were no significant differences between stents with no ISR and those with an ISR of less than 50% (P = .821) and between stents with an ISR of at least 50% and those with an ISR of 100% (P = .836). The CCO difference across coronary stents is related to ISR severity in

Robotic-assisted coronary artery bypass surgery: an 18-year single-centre experience.

PubMed

Giambruno, Vincenzo; Chu, Michael W; Fox, Stephanie; Swinamer, Stuart A; Rayman, Reiza; Markova, Zarina; Barnfield, Rebecca; Cooper, Mitchell; Boyd, Douglas W; Menkis, Alan; Kiaii, Bob

2018-06-01

Minimally invasive robot-assisted direct coronary artery bypass (RADCAB) has emerged as a feasible minimally invasive surgical technique for revascularization that might offer several potential advantages over conventional approaches. We present our 18-year experience in RADCAB. Between February 1998 and February 2016, 605 patients underwent RADCAB. Patients underwent post-procedural selective graft patency assessment using cardiac catheterization. The mortality rate was 0.3%. The rate of conversion to sternotomy for any cause was reduced from 16.0% of the first 200 cases to 6.9% of the last 405 patients. The patency rate of the LITA-to-LAD anastomosis was 97.4%. Surgical re-exploration for bleeding occurred in 1.8% of patients, and the transfusion rate was 9.2%. Average ICU stay was 1.2 ± 1.4 days, and average hospital stay was 4.8 ± 2.9 days. Robot-assisted coronary artery bypass grafting is safe, feasible and it seems to represent an effective alternative to traditional coronary artery bypass grafting in selected patients. Copyright © 2018 John Wiley & Sons, Ltd.

Elective minimally invasive coronary artery bypass: Shunt or tournique occlusion? Assessment of a protective role of perioperative left anterior descending shunting on myocardial damage. A prospective randomized study

PubMed Central

2012-01-01

Background To determine impact of intraluminal-left anterior descending shunt to prevent myocardial damage in minimally invasive coronary artery bypass. Methods 38 patients were randomly assigned to external tournique occlusion (n = 19) or intraluminal-left anterior descending shunt group (n = 19). Blood samples for cardiac troponin T were collected at 30 minutes prior to, 6 and 24 hours after surgery. Results One patient in external tournique occlusion and two patients in intraluminal-left anterior descending shunt group were excluded from futher analysis due to preoperative cardiac troponin T level above the 99th-percentile. Postoperatively, each six patients in external tournique occlusion (33.3%) and intraluminal-left anterior descending shunt (35.3%) group were above the 99th-percentile. Two patients from each group (external tournique occlusion group 11.1% vs. intraluminal-left anterior descending shunt group 11.8%) had peak values above 10-% coeficient of variation cutoff (p = 1). There were no significant differences in between both groups at all studied timepoints. Conclusion There was no protective effect of intraluminal shunting on myocardial damage compared to short-term tournique occlusion. It is upon the surgeon's discretion which method may preferrably be used to achieve a bloodless field in grafting of the non-occluded left anterior descending in minimally invasive coronary artery bypass. PMID:22809563

[Clinical significance of early percutaneous coronary intervention in patients with Braunwald III-B type unstable angina pectoris].

PubMed

Nozaki, Katsuhiro; Nakao, Koichi; Horiuchi, Kenji; Kasanuki, Hiroshi; Honda, Takashi

2003-06-01

To assess the efficacy of early invasive strategy for the treatment of Braunwald III-B type unstable angina pectoris. This study included 573 consecutive patients of whom 267 underwent percutaneous coronary intervention (PCI) (312 lesions). The patients were divided into two groups, 95 treated with the early invasive strategy of coronary angiography within 24 hr of admission (Group PCI-I) and the remaining 172 treated with the early conservative strategy of coronary angiography 24 hr after admission (Group PCI-C). No significant differences were noted in the baseline characteristics of the two groups except for ST segment elevation on electrocardiography at presentation, which occurred significantly less frequently in Group PCI-C (36.8% vs 8.1%, p < 0.0001). The initial success rate of percutaneous coronary intervention was sufficiently high in both groups (Group PCI-I: 96.9% vs Group PCI-C: 97.7%, NS). Acute myocardial infarction occurred in six patients of Group PCI-C (3.5%) because of the side branch occlusion. There was no in-hospital death or emergent coronary artery bypass grafting. During the 6-month follow-up, there were no significant differences in the death rates (2.1% vs 1.7%), the death or myocardial infarction rates (5.3% vs 5.8%) and the target lesion revascularization ratio (26.0% vs 25.7%) between Group PCI-I and Group PCI-C. The clinical outcomes of the early invasive strategy for unstable angina pectoris were almost equivalent to those of the early conservative strategy, despite more frequent ST segmental elevation at admission in Group PCI-I. These findings suggest that the early invasive strategy for unstable angina pectoris may be acceptable even in the current Japanese clinical setting without the use of GP IIb/IIIa receptor antagonist, low molecular weight heparin or clopidogrel.

Spontaneous Coronary Dissection: “Live Flash” Optical Coherence Tomography Guided Angioplasty

PubMed Central

Bento, Angela Pimenta; Fernandes, Renato Gil dos Santos Pinto; Neves, David Cintra Henriques Silva; Patrício, Lino Manuel Ribeiro; de Aguiar, José Eduardo Chambel

2016-01-01

Optical Coherence tomography (OCT) is a light-based imaging modality which shows tremendous potential in the setting of coronary imaging. Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome (ACS). The diagnosis of SCAD is made mainly with invasive coronary angiography, although adjunctive imaging modalities such as computed tomography angiography, IVUS, and OCT may increase the diagnostic yield. The authors describe a clinical case of a young woman admitted with the diagnosis of ACS. The ACS was caused by SCAD detected in the coronary angiography and the angioplasty was guided by OCT. OCT use in the setting of SCAD has been already described and the true innovation in this case was this unique use of OCT. The guidance of angioplasty with live and short images was very useful as it allowed clearly identifying the position of the guidewires at any given moment without the use of prohibitive amounts of contrast. PMID:26989520

Signal and image processing for early detection of coronary artery diseases: A review

NASA Astrophysics Data System (ADS)

Mobssite, Youness; Samir, B. Belhaouari; Mohamad Hani, Ahmed Fadzil B.

2012-09-01

Today biomedical signals and image based detection are a basic step to diagnose heart diseases, in particular, coronary artery diseases. The goal of this work is to provide non-invasive early detection of Coronary Artery Diseases relying on analyzing images and ECG signals as a combined approach to extract features, further classify and quantify the severity of DCAD by using B-splines method. In an aim of creating a prototype of screening biomedical imaging for coronary arteries to help cardiologists to decide the kind of treatment needed to reduce or control the risk of heart attack.

Effects of age on long-term outcomes after a routine invasive or selective invasive strategy in patients presenting with non-ST segment elevation acute coronary syndromes: a collaborative analysis of individual data from the FRISC II - ICTUS - RITA-3 (FIR) trials.

PubMed

Damman, Peter; Clayton, Tim; Wallentin, Lars; Lagerqvist, Bo; Fox, Keith A A; Hirsch, Alexander; Windhausen, Fons; Swahn, Eva; Pocock, Stuart J; Tijssen, Jan G P; de Winter, Robbert J

2012-02-01

To perform a patient-pooled analysis of a routine invasive versus a selective invasive strategy in elderly patients with non-ST segment elevation acute coronary syndrome. A meta-analysis was performed of patient-pooled data from the FRISC II-ICTUS-RITA-3 (FIR) studies. (Un)adjusted HRs were calculated by Cox regression, with adjustments for variables associated with age and outcomes. The main outcome was 5-year cardiovascular death or myocardial infarction (MI) following routine invasive versus selective invasive management. Regarding the 5-year composite of cardiovascular death or MI, the routine invasive strategy was associated with a lower hazard in patients aged 65-74 years (HR 0.72, 95% CI 0.58 to 0.90) and those aged ≥75 years (HR 0.71, 95% CI 0.55 to 0.91), but not in those aged <65 years (HR 1.11, 95% CI 0.90 to 1.38), p=0.001 for interaction between treatment strategy and age. The interaction was driven by an excess of early MIs in patients <65 years of age; there was no heterogeneity between age groups concerning cardiovascular death. The benefits were smaller for women than for men (p=0.009 for interaction). After adjustment for other clinical risk factors the HRs remained similar. The current analysis of the FIR dataset shows that the long-term benefit of the routine invasive strategy over the selective invasive strategy is attenuated in younger patients aged <65 years and in women by the increased risk of early events which seem to have no consequences for long-term cardiovascular mortality. No other clinical risk factors were able to identify patients with differential responses to a routine invasive strategy. Trial registration http://www.controlled-trials.com/ISRCTN82153174 (ICTUS), http://www.controlled-trials.com/ISRCTN07752711 (RITA-3).

Computed tomography-based diagnosis of diffuse compensatory enlargement of coronary arteries using scaling power laws.

PubMed

Huo, Yunlong; Choy, Jenny Susana; Wischgoll, Thomas; Luo, Tong; Teague, Shawn D; Bhatt, Deepak L; Kassab, Ghassan S

2013-04-06

Glagov's positive remodelling in the early stages of coronary atherosclerosis often results in plaque rupture and acute events. Because positive remodelling is generally diffused along the epicardial coronary arterial tree, it is difficult to diagnose non-invasively. Hence, the objective of the study is to assess the use of scaling power law for the diagnosis of positive remodelling of coronary arteries based on computed tomography (CT) images. Epicardial coronary arterial trees were reconstructed from CT scans of six Ossabaw pigs fed on a high-fat, high-cholesterol, atherogenic diet for eight months as well as the same number of body-weight-matched farm pigs fed on a lean chow (101.9±16.1 versus 91.5±13.1 kg). The high-fat diet Ossabaw pig model showed diffuse positive remodelling of epicardial coronary arteries. Good fit of measured coronary data to the length-volume scaling power law ( where L(c) and V(c) are crown length and volume) were found for both the high-fat and control groups (R(2) = 0.95±0.04 and 0.99±0.01, respectively). The coefficient, K(LV), decreased significantly in the high-fat diet group when compared with the control (14.6±2.6 versus 40.9±5.6). The flow-length scaling power law, however, was nearly unaffected by the positive remodelling. The length-volume and flow-length scaling power laws were preserved in epicardial coronary arterial trees after positive remodelling. K(LV) < 18 in the length-volume scaling relation is a good index of positive remodelling of coronary arteries. These findings provide a clinical rationale for simple, accurate and non-invasive diagnosis of positive remodelling of coronary arteries, using conventional CT scans.

Heart imaging: the accuracy of the 64-MSCT in the detection of coronary artery disease.

PubMed

Alessandri, N; Di Matteo, A; Rondoni, G; Petrassi, M; Tufani, F; Ferrari, R; Laghi, A

2009-01-01

At present, coronary angiography represents the gold standard technique for the diagnosis of coronary artery disease. Our aim is to compare the conventional coronary angiography to the coronary 64-multislice spiral computed tomography (64-MSCT), a new and non-invasive cardiac imaging technique. The last generation of MSCT scanners show a better imaging quality, due to a greater spatial and temporal resolution. Four expert observers (two cardiologists and two radiologists) have compared the angiographic data with the accuracy of the 64-MSCT in the detection and evaluation of coronary vessels stenoses. From the data obtained, the sensibility, the specificity and the accuracy of the coronary 64-MSCT have been defined. We have enrolled 75 patients (57 male, 18 female, mean age 61.83 +/- 10.38; range 30-80 years) with known or suspected coronary artery disease. The above population has been divided into 3 groups: Group A (Gr. A) with 40 patients (mean age 60.7 +/- 12.5) affected by both non-significant and significant coronary artery disease; Group B (Gr. B) with 25 patients (mean age 60.3 +/- 14.6) who underwent to percutaneous coronary intervention (PCI); Group C (Gr. C) with 10 patients (mean age 54.20 +/- 13.7) without any coronary angiographic stenoses. All the patients underwent non-invasive exams, conventional coronary angiography and coronary 64-MSCT. The comparison of the data obtained has been carried out according to a per group analysis, per patient analysis and per segment analysis. Moreover, the accuracy of the 64-MSCT has been defined for the detection of >75%, 50-75% and <50% coronary stenoses. Coronary angiography has identified significant coronary artery disease in 75% of the patients in the Gr. A and in 73% of the patients in the Gr. B. No coronary stenoses have been detected in Gr. C. According to a per segment analysis, in Gr. A, 36% of the segments analysed have shown a coronary stenosis (37% stenoses >75%, 32% stenoses 50-75% and 31% stenoses <50

Arterial Access in Patients With De Novo Acute Coronary Syndrome Undergoing Coronary Angiography.

PubMed

Abdul Jabbar, Ali; Mufti, Omar; Sabol, Angeline; Markert, Ronald; White, Bryan; Broderick, George

2017-04-01

Bleeding is a major limitation of antithrombotic therapy among invasively managed patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACSs). Randomized clinical trials have generally failed to favor either the femoral or the radial arterial approach for coronary angiography or intervention in NSTE-ACS. In 561 hospitalized patients with a new diagnosis of NSTE-ACS referred for coronary angiography, 364 and 197 patients underwent the femoral and the radial approach, respectively. Femoral and radial access did not differ in bleeding complications in the first 72 hours (8 of 364 or 2.2% vs 8 of 197 or 4.1%, P = .21), duration of hospitalization (4.67 ± 5.02 vs 4.51 ± 4.81, P = .28) nor in-hospital mortality (0.8% vs 0.5%, P = .67). Contrast volume was higher for femoral versus radial cases (204 ± 119 vs 168 ± 104, P < .001). In patients with de novo NSTE-ACS without prior cardiac bypass, radial and femoral arterial access did not differ in instances of bleeding within the first 72 hours postoperatively, length of hospital stay, or in-hospital mortality. Less contrast was used in radial cases, which may represent an advantage for patients with renal insufficiency.

Acceptance of Combined Coronary CT Angiography and Myocardial CT Perfusion versus Conventional Coronary Angiography in Patients with Coronary Stents—Intraindividual Comparison

PubMed Central

Martus, Peter; Laule, Michael; Dewey, Marc; Schönenberger, Eva

2015-01-01

Objectives To evaluate how well patients with coronary stents accept combined coronary computed tomography angiography (CTA) and myocardial CT perfusion (CTP) compared with conventional coronary angiography (CCA). Background While combined CTA and CTP may improve diagnostic accuracy compared with CTA alone, patient acceptance of CTA/CTP remains to be defined. Methods A total of 90 patients with coronary stents prospectively underwent CTA/CTP (both with contrast agent, CTP with adenosine) and CCA as part of the CARS-320 study. In this group, an intraindividual comparison of patient acceptance of CTA, CTP, and CCA was performed. Results CTP was experienced to be significantly more painful than CTA (p<0.001) and was associated with a higher frequency of dyspnea (p<0.001). Comparison of CTA/CTP with CCA revealed no significant differences in terms of pain (p = 0.141) and comfort (p = 0.377). Concern before CTA/CTP and CCA and overall satisfaction were likewise not significantly different (p = 0.097 and p = 0.123, respectively). Nevertheless, about two thirds (n = 60, 68%) preferred CTA/CTP to CCA (p<0.001). Moreover, patients felt less helpless during CTA/CTP than during CCA (p = 0.026). Lack of invasiveness and absence of pain were the most frequently mentioned advantages of CTA/CTP over CCA in our patient population. Conclusions CCA and combined CTA/CTP are equally well accepted by patients; however, more patients prefer CTA/CTP. CTP was associated with more intense pain than CTA and more frequently caused dyspnea than CTA alone. Trial Registration ClinicalTrials.gov NCT00967876 PMID:26327127

Advanced 2-dimensional quantitative coronary angiographic analysis for prediction of fractional flow reserve in intermediate coronary stenoses.

PubMed

Opolski, Maksymilian P; Pregowski, Jerzy; Kruk, Mariusz; Kepka, Cezary; Staruch, Adam D; Witkowski, Adam

2014-07-01

The widespread clinical application of coronary computed tomography angiography (CCTA) has resulted in increased referral patterns of patients with intermediate coronary stenoses to invasive coronary angiography. We evaluated the application of advanced quantitative coronary angiography (A-QCA) for predicting fractional flow reserve (FFR) in intermediate coronary lesions detected on CCTA. Fifty-six patients with 66 single intermediate coronary lesions (≥ 50% to 80% stenosis) on CCTA prospectively underwent coronary angiography and FFR. A-QCA including calculation of the Poiseuille-based index defined as the ratio of lesion length to the fourth power of the minimal lumen diameter (MLD) was performed. Significant stenosis was defined as FFR ≤ 0.80. The mean FFR was 0.86 ± 0.09, and 18 lesions (27%) were functionally significant. FFR correlated with lesion length (R=-0.303, P=0.013), MLD (R=0.527, P<0.001), diameter stenosis (R=-0.404, P=0.001), minimum lumen area (MLA) (R=0.530, P<0.001), lumen stenosis (R=-0.400, P=0.001), and Poiseuille-based index (R=-0.602, P<0.001). The optimal cutoff values for MLD, MLA, diameter stenosis, and lumen stenosis were ≤ 1.3 mm, ≤ 1.5 mm, >44%, and >69%, respectively (maximum negative predictive value of 94% for MLA, maximum positive predictive value of 58% for diameter stenosis). The Poiseuille-based index was the most accurate (C statistic 0.86, sensitivity 100%, specificity 71%, positive predictive value 56%, and negative predictive value 100%) predictor of FFR ≤ 0.80, but showed the lowest interobserver agreement (intraclass correlation coefficient 0.37). A-QCA might be used to rule out significant ischemia in intermediate stenoses detected by CCTA. The diagnostic application of the Poiseuille-based angiographic index is precluded by its high interobserver variability.

Minimally Invasive Mitral Valve Procedures: The Current State

PubMed Central

Ritwick, Bhuyan; Chaudhuri, Krishanu; Crouch, Gareth; Edwards, James R. M.; Worthington, Michael; Stuklis, Robert G.

2013-01-01

Since its early days, cardiac surgery has typically involved large incisions with complete access to the heart and the great vessels. After the popularization of the minimally invasive techniques in general surgery, cardiac surgeons began to experiment with minimal access techniques in the early 1990s. Although the goals of minimally invasive cardiac surgery (MICS) are fairly well established as decreased pain, shorter hospital stay, accelerated recuperation, improved cosmesis, and cost effectiveness, a strict definition of minimally invasive cardiac surgery has been more elusive. Minimally invasive cardiac surgery started with mitral valve procedures and then gradually expanded towards other valve procedures, coronary artery bypass grafting, and various types of simple congenital heart procedures. In this paper, the authors attempt to focus on the evolution, techniques, results, and the future perspective of minimally invasive mitral valve surgery (MIMVS). PMID:24382998

Vasomotor symptoms among Japanese-American and European-American women living in Hilo, Hawaii.

PubMed

Sievert, Lynnette Leidy; Morrison, Lynn; Brown, Daniel E; Reza, Angela M

2007-01-01

The Hilo Women's Health Survey was designed and administered to gather baseline data on women's health in Hilo, HI. This randomized, cross-sectional study allowed for a focus on ethnic differences in symptom reporting. The results presented here focus on hot flash and night sweat experience among Japanese-American and European-American women. Survey packets were mailed to street addresses associated with parcel numbers pulled randomly from Hilo tax maps. Of the 6,401 survey packets delivered to households, 1,824 questionnaires were completed and returned. The results reported here are based on 869 women aged 40 to 60, of whom 249 described themselves to be 100% Japanese and 203 described themselves to be 100% European-American. Logistic regression analyses were used to examine whether the relationship between ethnicity and vasomotor symptoms persisted after controlling for other variables. European-American participants were more likely to have ever experienced a hot flash as compared with Japanese-American participants (72% vs 53%, P<0.01). During the 2 weeks before the survey, European-American participants were more likely to have experienced hot flashes (P<0.05) and night sweats (P<0.01). In logistic regression analyses, after controlling for age, body mass index, menopause status, level of education, financial comfort, smoking habits, alcohol intake, exercise, use of hormone therapy, and soy intake, European-American women were still significantly more likely to have experienced hot flashes (odds ratio=1.858) and night sweats (odds ratio=2.672). The results, based on self-reporting of menopausal symptoms, indicate that Japanese-American women report fewer hot flashes and night sweats than European-American women. Japanese-American women reported a higher intake of soy, but soy intake was not associated with fewer vasomotor symptoms.

The effect of foot reflexology applied to women aged between 40 and 60 on vasomotor complaints and quality of life.

PubMed

Gozuyesil, Ebru; Baser, Muruvvet

2016-08-01

This study aims to identify the effects of foot reflexology applied to women on their vasomotor complaints and quality of life. A randomised controlled study was conducted with 120 women. The experimental group received foot reflexology treatment, while the control group received nonspecific foot massage. The mean scores for hot flashes, sweats, and night sweats, were lower in the reflexology group than the control group after the practice; and the difference between the groups was statistically significant (p < 0.001). The mean scores for the sub-groups of the MENQOL demonstrated improvements in both groups after the application (p < 0.001). As for the sexual domain, there was a significant improvement in the reflexology group (p < 0.05), but no improvements were found in the control group (p > 0.05). Results showed that reflexology might be effective in decreasing vasomotor problems and increasing quality of life in women in the menopausal period. Copyright © 2016 Elsevier Ltd. All rights reserved.

Minimally Invasive Extracorporeal Circulation Circuit Is Not Inferior to Off-Pump Coronary Artery Bypass Grafting: Meta-Analysis Using the Bayesian Method.

PubMed

Winkler, Bernhard; Heinisch, Paul P; Gahl, Brigitta; Aghlmandi, Soheila; Jenni, Hans Jörg; Carrel, Thierry P

2017-01-01

The pathophysiologic side effects of cardiopulmonary bypass have already been identified. Minimally invasive extracorporeal circulation technologies (MiECT) and off-pump coronary artery bypass graft surgery (OPCABG) aim to reduce these problems. This meta-analysis provides a comparison of MiECT and OPCABG in randomized and observational studies. A fully probabilistic, Bayesian approach of primary and secondary endpoints was conducted. MiECT does not give inferior results when compared with OPCABG. However, there is a trend to borderline significantly higher blood loss in this group in randomized controlled trials. The question whether MiECT is equivalent to OPCABG can be answered with the affirmative, but long-term follow-up data are needed to detect any advantage over time. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Methodological quality of diagnostic accuracy studies on non-invasive coronary CT angiography: influence of QUADAS (Quality Assessment of Diagnostic Accuracy Studies included in systematic reviews) items on sensitivity and specificity.

PubMed

Schueler, Sabine; Walther, Stefan; Schuetz, Georg M; Schlattmann, Peter; Dewey, Marc

2013-06-01

To evaluate the methodological quality of diagnostic accuracy studies on coronary computed tomography (CT) angiography using the QUADAS (Quality Assessment of Diagnostic Accuracy Studies included in systematic reviews) tool. Each QUADAS item was individually defined to adapt it to the special requirements of studies on coronary CT angiography. Two independent investigators analysed 118 studies using 12 QUADAS items. Meta-regression and pooled analyses were performed to identify possible effects of methodological quality items on estimates of diagnostic accuracy. The overall methodological quality of coronary CT studies was merely moderate. They fulfilled a median of 7.5 out of 12 items. Only 9 of the 118 studies fulfilled more than 75 % of possible QUADAS items. One QUADAS item ("Uninterpretable Results") showed a significant influence (P = 0.02) on estimates of diagnostic accuracy with "no fulfilment" increasing specificity from 86 to 90 %. Furthermore, pooled analysis revealed that each QUADAS item that is not fulfilled has the potential to change estimates of diagnostic accuracy. The methodological quality of studies investigating the diagnostic accuracy of non-invasive coronary CT is only moderate and was found to affect the sensitivity and specificity. An improvement is highly desirable because good methodology is crucial for adequately assessing imaging technologies. • Good methodological quality is a basic requirement in diagnostic accuracy studies. • Most coronary CT angiography studies have only been of moderate design quality. • Weak methodological quality will affect the sensitivity and specificity. • No improvement in methodological quality was observed over time. • Authors should consider the QUADAS checklist when undertaking accuracy studies.

Sudomotor, skin vasomotor, and cardiovascular reflexes in 3 clinical forms of Lewy body disease.

PubMed

Akaogi, Y; Asahina, M; Yamanaka, Y; Koyama, Y; Hattori, T

2009-07-07

To elucidate the differences among dementia with Lewy bodies (DLB), Parkinson disease with dementia (PDD), and Parkinson disease without dementia (PD), with respect to the involvement of the autonomic nervous system, we clinically investigated the cutaneous and cardiovascular autonomic functions in patients with Lewy body disease. We studied 36 patients with Lewy body disorders, including 12 patients with DLB (age, 75.4 +/- 5.9 years), 12 patients with PDD (71.0 +/- 6.8 years), and 12 patients with PD (70.9 +/- 4.2 years), and 12 healthy control subjects (69.9 +/- 5.3 years). Sympathetic sweat response (SSwR) and skin vasomotor reflex (SkVR) on the palm were recorded to estimate the cutaneous sympathetic function, and the head-up tilt test was performed and coefficient of variation of R-R intervals (CV(R-R)) was studied to estimate the cardiovascular function. The patients with DLB, patients with PDD, and patients with PD showed severely reduced SSwR amplitudes, significantly lower than that in the controls. The mean SkVR amplitudes in the patients with DLB and patients with PDD were significantly lower than that in the controls, but not in the patients with PD. The mean decreases in the systolic blood pressure during the head-up tilt test in the patients with DLB and patients with PDD were less than that in the controls. The mean CV(R-R) value was significantly lower in the patients with DLB. Sudomotor function on the palm may be severely affected in Lewy body disorders, while skin vasomotor function and the cardiovascular system may be more severely affected in dementia with Lewy bodies and Parkinson disease with dementia than in Parkinson disease.

Imaging of all three coronary arteries by transthoracic echocardiography. an illustrated guide

PubMed Central

Krzanowski, Marek; Bodzoń, Wojciech; Dimitrow, Paweł Petkow

2003-01-01

Background Improvements in ultrasound technology has enabled direct, transthoracic visualization of long portions of coronary arteries : the left anterior descending (LAD), circumflex (Cx) and right coronary artery (RCA). Transthoracic measurements of coronary flow velocity were proved to be highly reproducible and correlated with invasive measurements. While clinical applications of transthoracic echocardiography (TTE) of principal coronary arteries are still very limited they will likely grow. The echocardiographers may therefore be interested to know the ultrasonic views, technique of examination and be aware where to look for coronary arteries and how to optimize the images. Methods A step-by-step approach to direct, transthoracic visualization of the LAD, Cx and RCA is presented. The technique of examination is discussed, correlations with basic coronary angiography views and heart anatomy are shown and extensively illustrated with photographs and movie-pictures. Hints concerning optimization of ultrasound images are presented and artifacts of imaging are discussed. Conclusions Direct, transthoracic examination of the LAD, Cx and RCA in adults is possible and may become a useful adjunct to other methods of coronary artery examination but studies are needed to establish its role. PMID:14622441

Catheter-based treatment of coronary artery disease: past, present, and future.

PubMed

Holmes, David R; Williams, David O

2008-08-01

September 2007 marked the 30-year anniversary of the first human percutaneous coronary intervention, an index event that changed the course of modern-day cardiovascular care. Before that first procedure, adult invasive cardiology focused on diagnostic angiography as well as hemodynamic assessment of structural heart disease. Since that initial procedure, percutaneous coronary intervention has become the most frequently performed coronary revascularization procedure worldwide. Several factors have been responsible for this dramatic paradigm shift, the most prominent being identification of opportunities for technical improvement and the application of innovation and investigation in concert with colleagues, professional societies, and industry. These approaches will continue to be of paramount importance as new technologies are brought to bear on an increasingly broader group of patients with cardiovascular disease.

Current indications for left thoracotomy in coronary revascularization and valvular procedures.

PubMed

Pratt, J W; Williams, T E; Michler, R E; Brown, D A

2000-10-01

Left thoracotomy is infrequently used for cardiac procedures, but its application in reoperative and minimally invasive coronary revascularization and in valvular procedures has been reported recently. Three case reports and a review of the current literature illustrate the unique benefits of this approach for myocardial revascularization and valve replacement. Reoperative coronary revascularization of the left anterior descending and circumflex coronary arteries was performed off-pump via a left posterolateral thoracotomy. For the second case, this approach was used for coronary artery bypass grafting of the right coronary and left anterior descending arteries with femoral-femoral cardiopulmonary bypass in a patient with congestive heart failure and coronary artery disease who also required closure of a patent ductus arteriosus. In the third case, mitral valve replacement using femoral venous and aortic cannulation for cardiopulmonary bypass was performed via a left thoracotomy to avoid a retrosternal gastric conduit in a patient with severe mitral stenosis and congestive heart failure. All patients returned to normal activity and are asymptomatic. These case reports and a comprehensive review of the literature demonstrate the utility of left thoracotomy as an alternative approach to standard median sternotomy in selected cases of revascularization and valvular procedures.

Optimal timing of coronary angiography and potential intervention in non-ST-elevation acute coronary syndromes.

PubMed

Katritsis, Demosthenes G; Siontis, George C M; Kastrati, Adnan; van't Hof, Arnoud W J; Neumann, Franz-Josef; Siontis, Konstantinos C M; Ioannidis, John P A

2011-01-01

An invasive approach is superior to medical management for the treatment of patients with acute coronary syndromes without ST-segment elevation (NSTE-ACS), but the optimal timing of coronary angiography and subsequent intervention, if indicated, has not been settled. We conducted a meta-analysis of randomized trials addressing the optimal timing (early vs. delayed) of coronary angiography in NSTE-ACS. Four trials with 4013 patients were eligible (ABOARD, ELISA, ISAR-COOL, TIMACS), and data for longer follow-up periods than those published became available for this meta-analysis by the ELISA and ISAR-COOL investigators. The median time from admission or randomization to coronary angiography ranged from 1.16 to 14 h in the early and 20.8-86 h in the delayed strategy group. No statistically significant difference of risk of death [random effects risk ratio (RR) 0.85, 95% confidence interval (CI) 0.64-1.11] or myocardial infarction (MI) (RR 0.94, 95% CI 0.61-1.45) was detected between the two strategies. Early intervention significantly reduced the risk for recurrent ischaemia (RR 0.59, 95% CI 0.38-0.92, P = 0.02) and the duration of hospital stay (by 28%, 95% CI 22-35%, P < 0.001). Furthermore, decreased major bleeding events (RR 0.78, 95% CI 0.57-1.07, P = 0.13), and less major events (death, MI, or stroke) (RR 0.91, 95% CI 0.82-1.01, P = 0.09) were observed with the early strategy but these differences were not nominally significant. Early coronary angiography and potential intervention reduces the risk of recurrent ischaemia, and shortens hospital stay in patients with NSTE-ACS.

Noninvasive Fractional Flow Reserve Derived From Coronary CT Angiography: Clinical Data and Scientific Principles.

PubMed

Min, James K; Taylor, Charles A; Achenbach, Stephan; Koo, Bon Kwon; Leipsic, Jonathon; Nørgaard, Bjarne L; Pijls, Nico J; De Bruyne, Bernard

2015-10-01

Fractional flow reserve derived from coronary computed tomography angiography enables noninvasive assessment of the hemodynamic significance of coronary artery lesions and coupling of the anatomic severity of a coronary stenosis with its physiological effects. Since its initial demonstration of feasibility of use in humans in 2011, a significant body of clinical evidence has developed to evaluate the diagnostic performance of coronary computed tomography angiography-derived fractional flow reserve compared with an invasive fractional flow reserve reference standard. The purpose of this paper was to describe the scientific principles and to review the clinical data of this technology recently approved by the U.S. Food and Drug Administration. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Sex Differences in Percutaneous Coronary Intervention-Insights From the Coronary Angiography and PCI Registry of the German Society of Cardiology.

PubMed

Heer, Tobias; Hochadel, Matthias; Schmidt, Karin; Mehilli, Julinda; Zahn, Ralf; Kuck, Karl-Heinz; Hamm, Christian; Böhm, Michael; Ertl, Georg; Hoffmeister, Hans Martin; Sack, Stefan; Senges, Jochen; Massberg, Steffen; Gitt, Anselm K; Zeymer, Uwe

2017-03-20

Several studies have suggested sex-related differences in diagnostic and invasive therapeutic coronary procedures. Data from consecutive patients who were enrolled in the Coronary Angiography and PCI Registry of the German Society of Cardiology were analyzed. We aimed to compare sex-related differences in in-hospital outcomes of patients undergoing percutaneous coronary intervention (PCI) for stable coronary artery disease, non-ST elevation acute coronary syndromes, ST elevation myocardial infarction, and cardiogenic shock. From 2007 until the end of 2009 data from 185 312 PCIs were prospectively registered: 27.9% of the PCIs were performed in women. Primary PCI success rate was identical between the sexes (94%). There were no sex-related differences in hospital mortality among patients undergoing PCI for stable coronary artery disease, non-ST elevation acute coronary syndromes, or cardiogenic shock except among ST elevation myocardial infarction patients. Compared to men, women undergoing primary PCI for ST elevation myocardial infarction have a higher risk of in-hospital death, age-adjusted odds ratio (1.19, 95% CI 1.06-1.33), and risk of ischemic cardiac and cerebrovascular events (death, myocardial infarction, transient ischemic attack/stroke), (age-adjusted odds ratio 1.19, 95% CI 1.16-1.29). Furthermore, access-related complications were twice as high in women, irrespective of the indication. Despite identical technical success rates of PCI between the 2 sexes, women with PCI for ST elevation myocardial infarction have a 20% higher age-adjusted risk of death and of ischemic cardiac and cerebrovascular events. Further research is needed to determine the reasons for these differences. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Anomalous Coronary Arteries and Myocardial Bridges: Risk Stratification in Children Using Novel Cardiac Catheterization Techniques.

PubMed

Agrawal, Hitesh; Molossi, Silvana; Alam, Mahboob; Sexson-Tejtel, S Kristen; Mery, Carlos M; McKenzie, E Dean; Fraser, Charles D; Qureshi, Athar M

2017-03-01

The evaluation of the vast majority of children with anomalous aortic origin of a coronary artery (AAOCA) and/or myocardial bridges is performed with non-invasive testing. However, a subset of these patients may benefit from invasive testing for risk stratification. All patients included in the Coronary Anomalies Program (CAP) at Texas Children's Hospital who underwent cardiac catheterization were included. Techniques included selective coronary angiograms (SCA), intravascular ultrasound (IVUS), and fractional flow reserve (FFR) measurements with provocative testing using adenosine and/or dobutamine infusions. Out of the 131 patients followed by the CAP between 12/12-4/16, 8 (6%) patients underwent 9 cath investigations at median age 13.1 (2.6-18.7) years and median weight 49.5 (11.4-142.7) kg. Six patients presented with cardiac signs/symptoms. Four patients had myocardial bridges of the left anterior descending (LAD) coronary artery, 2 patients had isolated AAOCA, and 2 patients had an anomalous left coronary artery (LCA) with an intramyocardial course of the LAD. SCA was performed in all patients. FFR was positive in 4/6 patients: IVUS showed >70% intraluminal narrowing in 3/5 patients. One patient had hemodynamic instability that reversed with catheter removal from the coronary ostium. Based on the catheterization data obtained, findings were reassuring in three patients, surgery was performed in three patients, and two patients are being medically managed/restricted from competitive sports. In our small cohort of patients, we demonstrated that IVUS and FFR can safely be performed in children and may help to risk stratify some patients with AAOCA and myocardial bridges.

Osteocalcin expression by circulating endothelial progenitor cells in patients with coronary atherosclerosis.

PubMed

Gössl, Mario; Mödder, Ulrike I; Atkinson, Elizabeth J; Lerman, Amir; Khosla, Sundeep

2008-10-14

This study was designed to test whether patients with coronary atherosclerosis have increases in circulating endothelial progenitor cells (EPCs) expressing an osteogenic phenotype. Increasing evidence indicates a link between bone and the vasculature, and bone marrow and circulating osteogenic cells have been identified by staining for the osteoblastic marker, osteocalcin (OCN). Endothelial progenitor cells contribute to vascular repair, but repair of vascular injury may result in calcification. Using cell surface markers (CD34, CD133, kinase insert domain receptor [KDR]) to identify EPCs, we examined whether patients with coronary atherosclerosis had increases in the percentage of EPCs expressing OCN. We studied 72 patients undergoing invasive coronary assessment: control patients (normal coronary arteries and no endothelial dysfunction, n = 21) versus 2 groups with coronary atherosclerosis-early coronary atherosclerosis (normal coronary arteries but with endothelial dysfunction, n = 22) and late coronary atherosclerosis (severe, multivessel coronary artery disease, n = 29). Peripheral blood mononuclear cells were analyzed using flow cytometry. Compared with control patients, patients with early or late coronary atherosclerosis had significant increases (approximately 2-fold) in the percentage of CD34+/KDR+ and CD34+/CD133+/KDR+ cells costaining for OCN. Even larger increases were noted in the early and late coronary atherosclerosis patients in the percentage of CD34+/CD133-/KDR+ cells costaining for OCN (5- and 2-fold, p < 0.001 and 0.05, respectively). A higher percentage of EPCs express OCN in patients with coronary atherosclerosis compared with subjects with normal endothelial function and no structural coronary artery disease. These findings have potential implications for the mechanisms of vascular calcification and for the development of novel markers for coronary atherosclerosis.

SPECT myocardial perfusion imaging as an adjunct to coronary calcium score for the detection of hemodynamically significant coronary artery stenosis

PubMed Central

2012-01-01

Background Coronary artery calcifications (CAC) are markers of coronary atherosclerosis, but do not correlate well with stenosis severity. This study intended to evaluate clinical situations where a combined approach of coronary calcium scoring (CS) and nuclear stress test (SPECT-MPI) is useful for the detection of relevant CAD. Methods Patients with clinical indication for invasive coronary angiography (ICA) were included into our study during 08/2005-09/2008. At first all patients underwent CS procedure as part of the study protocol performed by either using a multidetector computed tomography (CT) scanner or a dual-source CT imager. CAC were automatically defined by dedicated software and the Agatston score was semi-automatically calculated. A stress-rest SPECT-MPI study was performed afterwards and scintigraphic images were evaluated quantitatively. Then all patients underwent ICA. Thereby significant CAD was defined as luminal stenosis ≥75% in quantitative coronary analysis (QCA) in ≥1 epicardial vessel. To compare data lacking Gaussian distribution an unpaired Wilcoxon-Test (Mann–Whitney) was used. Otherwise a Students t-test for unpaired samples was applied. Calculations were considered to be significant at a p-value of <0.05. Results We consecutively included 351 symptomatic patients (mean age: 61.2±12.3 years; range: 18–94 years; male: n=240) with a mean Agatston score of 258.5±512.2 (range: 0–4214). ICA verified exclusion of significant CAD in 66/67 (98.5%) patients without CAC. CAC was detected in remaining 284 patients. In 132/284 patients (46.5%) with CS>0 significant CAD was confirmed by ICA, and excluded in 152/284 (53.5%) patients. Sensitivity for CAD detection by CS alone was calculated as 99.2%, specificity was 30.3%, and negative predictive value was 98.5%. An additional SPECT in patients with CS>0 increased specificity to 80.9% while reducing sensitivity to 87.9%. Diagnostic accuracy was 84.2%. Conclusions In patients without CS=0

Coronary CT Angiography-derived Fractional Flow Reserve: Machine Learning Algorithm versus Computational Fluid Dynamics Modeling.

PubMed

Tesche, Christian; De Cecco, Carlo N; Baumann, Stefan; Renker, Matthias; McLaurin, Tindal W; Duguay, Taylor M; Bayer, Richard R; Steinberg, Daniel H; Grant, Katharine L; Canstein, Christian; Schwemmer, Chris; Schoebinger, Max; Itu, Lucian M; Rapaka, Saikiran; Sharma, Puneet; Schoepf, U Joseph

2018-04-10

Purpose To compare two technical approaches for determination of coronary computed tomography (CT) angiography-derived fractional flow reserve (FFR)-FFR derived from coronary CT angiography based on computational fluid dynamics (hereafter, FFR CFD ) and FFR derived from coronary CT angiography based on machine learning algorithm (hereafter, FFR ML )-against coronary CT angiography and quantitative coronary angiography (QCA). Materials and Methods A total of 85 patients (mean age, 62 years ± 11 [standard deviation]; 62% men) who had undergone coronary CT angiography followed by invasive FFR were included in this single-center retrospective study. FFR values were derived on-site from coronary CT angiography data sets by using both FFR CFD and FFR ML . The performance of both techniques for detecting lesion-specific ischemia was compared against visual stenosis grading at coronary CT angiography, QCA, and invasive FFR as the reference standard. Results On a per-lesion and per-patient level, FFR ML showed a sensitivity of 79% and 90% and a specificity of 94% and 95%, respectively, for detecting lesion-specific ischemia. Meanwhile, FFR CFD resulted in a sensitivity of 79% and 89% and a specificity of 93% and 93%, respectively, on a per-lesion and per-patient basis (P = .86 and P = .92). On a per-lesion level, the area under the receiver operating characteristics curve (AUC) of 0.89 for FFR ML and 0.89 for FFR CFD showed significantly higher discriminatory power for detecting lesion-specific ischemia compared with that of coronary CT angiography (AUC, 0.61) and QCA (AUC, 0.69) (all P < .0001). Also, on a per-patient level, FFR ML (AUC, 0.91) and FFR CFD (AUC, 0.91) performed significantly better than did coronary CT angiography (AUC, 0.65) and QCA (AUC, 0.68) (all P < .0001). Processing time for FFR ML was significantly shorter compared with that of FFR CFD (40.5 minutes ± 6.3 vs 43.4 minutes ± 7.1; P = .042). Conclusion The FFR ML algorithm performs equally in

Chest pain: coronary CT in the ER

PubMed Central

Maffei, Erica; Seitun, Sara; Guaricci, Andrea I

2016-01-01

Cardiac CT has developed into a robust clinical tool during the past 15 years. Of the fields in which the potential of cardiac CT has raised more interest is chest pain in acute settings. In fact, the possibility to exclude with high reliability obstructive coronary artery disease (CAD) in patients at low-to-intermediate risk is of great interest both from the clinical standpoint and from the management standpoint. Several other modalities, with or without imaging, have been used during the past decades in the settings of new onset chest pain or in acute chest pain for both diagnostic and prognostic assessment of CAD. Each one has advantages and disadvantages. Most imaging modalities also focus on inducible ischaemia to guide referral to invasive coronary angiography. The advent of cardiac CT has introduced a new practice diagnostic paradigm, being the most accurate non-invasive method for identification and exclusion of CAD. Furthermore, the detection of subclinical CAD and plaque imaging offer the opportunity to improve risk stratification. Moreover, recent advances of the latest generation CT scanners allow combining both anatomical and functional imaging by stress myocardial perfusion. The role of cardiac CT in acute settings is already important and will become progressively more important in the coming years. PMID:26866681

Invasive Management Strategies and Antithrombotic Treatments in Patients With Non-ST-Segment-Elevation Acute Coronary Syndrome in China: Findings From the Improving CCC Project (Care for Cardiovascular Disease in China).

PubMed

Yang, Qing; Wang, Ying; Liu, Jing; Liu, Jun; Hao, Yongchen; Smith, Sidney C; Huo, Yong; Fonarow, Gregg C; Ma, Changsheng; Ge, Junbo; Taubert, Kathryn A; Morgan, Louise; Guo, Yang; Wang, Wei; Zhou, Yujie; Zhao, Dong

2017-06-01

Early invasive strategies and antithrombotic treatments are key treatments of non-ST-segment-elevation acute coronary syndrome (NSTE-ACS). Few studies have examined the use of these strategies in patients with NSTE-ACS in China. This study aimed to assess the applications of invasive strategies and antithrombotic treatments in patients with NSTE-ACS and compare their outcomes. A nationwide registry study, Improving CCC (Care for Cardiovascular Disease in China) ACS project, was launched in 2014 as a collaborative study of the American Heart Association and Chinese Society of Cardiology (CSC), with 142 participating hospitals reporting details of clinical management and outcomes of patients with NSTE-ACS. The use of invasive strategies and antithrombotic treatments was examined based on updated guidelines. Major adverse cardiovascular events were analyzed. A total of 9953 patients with NSTE-ACS were enrolled. Angiography was performed in 63.1% of these patients, and 58.2% underwent percutaneous coronary intervention (PCI). However, 40.6% of patients did not undergo early risk assessment, and very-high-risk patients had the lowest proportion of PCI (41.7%). PCI was performed within recommended times in 11.1% of very-high-risk patients and 26.3% of high risk patients. Those who underwent PCI within 2 hours had higher mortality in high-risk and very-high-risk patients who received PCI. Early dual antiplatelet treatment was given in 88.3% of patients. There are notable differences between guideline recommendations and the clinical management of patients with NSTE-ACS in China. The reasons for very-high-risk NSTE-ACS patients not undergoing PCI, and the optimal timing of PCI, require further clarification. URL: http://www.clinicaltrials.gov. Unique identifier: NCT02306616. © 2017 American Heart Association, Inc.

[Effect of soybeans and soy sauce on vasomotor symptoms during menopause].

PubMed

Gutiérrez Martínez, María Del Mar; Riquelme Raya, Rebeca; Campos Martínez, Ana María; Lorite Garzón, Catalina; Strivens Vilchez, Helen; Ruiz Rodríguez, Concepción

2006-06-01

During menopause, some women experience symptoms which can interfere with their living quality. Some of these symptoms are the so-called vasomotor symptoms which include suffocations, hot flashes, and nocturnal sweats. Up to now, the most effective remedy was hormone treatment, but a study of isoflavines, such as soybean, suggests it is possible to alleviate the disturbances caused by menopause. Due to this study we consider that the addition of isoflavines can provide benefits to women. Therefore, it is correct to include them in the field of medicines which give an alternative to estrogen therapy. However, one must bear in mind that data about the efficiency and security of alternative medicines in the treatment of menopause symptoms are not conclusive since each woman is unique and it is necessary to have consensus on an individualized health plan which permits one to carry out adequate therapeutic adjustments in accordance to the needs which occur over the entire menopause process.

Hybrid coronary revascularization in the era of drug-eluting stents.

PubMed

Murphy, Gavin J; Bryan, Alan J; Angelini, Gianni D

2004-11-01

Left internal mammary artery to left anterior descending coronary artery bypass grafting integrated with percutaneous coronary angioplasty (hybrid procedure) offers multivessel revascularization with minimal morbidity in high-risk patients. This is caused in part by the avoidance of cardiopulmonary bypass-related morbidity and manipulation of the aorta coupled with minimally invasive techniques. Hybrid revascularization is currently reserved for particularly high-risk patients or those with favorable anatomic variants however, largely because of the emergence of off-pump coronary artery bypass grafting, which permits more complete multivessel revascularization, with low morbidity in high-risk groups. The wider introduction of hybrid revascularization is limited chiefly by the high number of repeat interventions compared with off-pump coronary artery bypass grafting, which occurs because of the target vessel failure rate of percutaneous coronary intervention. Other demerits are the costs and logistic problems associated with performing two procedures with differing periprocedural management protocols. Recently, drug-eluting stents have reduced the need for repeat intervention after percutaneous coronary intervention, and this has raised the possibility that the results of hybrid revascularization may now equal or even better those of off-pump coronary artery bypass grafting. Although undoubtedly effective at reducing in-stent restenosis, drug-eluting stents will not address the issues of incomplete revascularization or the logistic problems associated with hybrid. Uncertainty regarding the long-term effectiveness of drug-eluting stents in many patients, as well as their high cost when compared with those of off-pump coronary artery bypass grafting surgery, also militates against the wider introduction of hybrid revascularization.

Acute coronary syndrome in the elderly.

PubMed

Shanmugasundaram, Madhan; Alpert, Joseph S

2009-11-01

The spectrum of acute coronary syndrome (ACS) including unstable angina, non-ST-elevation myocardial infarction and ST-elevation myocardial infarction accounts for increasing numbers of deaths among persons age > or = 65 years in the US. This is important given demographic changes involving falling birth rates and increasing life expectancy. Elderly patients are likely to benefit the most from treatment of ACS, even though community practice still demonstrates less use of cardiac medications as an early-invasive approach among this population.

Sustained conduction of vasomotor responses in rat mesenteric arteries in a two-compartment in vitro setup.

PubMed

Palao, Teresa; van Weert, Angela; de Leeuw, Anne; de Vos, Judith; Bakker, Erik N T P; van Bavel, Ed

2018-05-21

Conduction of vasomotor responses may contribute to long-term regulation of resistance artery function and structure. Most previous studies have addressed conduction of vasoactivity only during very brief stimulations. We developed a novel setup that allows the local pharmacological stimulation of arteries in vitro for extended periods of time, and studied the conduction of vasomotor responses in rat mesenteric arteries under those conditions. The new in vitro set up was based on the pressure myograph. The superfusion chamber was divided halfway along the vessel into two compartments, allowing an independent superfusion of the arterial segment in each compartment. Local and remote cumulative concentration-response curves were obtained for a range of vasoactive agents. Additional experiments were performed with the gap junction inhibitor 18β-glycyrrhetinic acid and in absence of the endothelium. Phenylephrine-induced constriction and acetylcholine-induced dilation were conducted over a measured distance up to 2.84 mm, and this conduction was maintained for 5 minutes. Conduction of acetylcholine-induced dilation was inhibited by 18β-glycyrrhetinic acid and conduction of phenylephrine-induced constriction was abolished in absence of the endothelium. Constriction in response to high K + was not conducted. Absence of remote stimulation dampened the local response to phenylephrine. This study demonstrates maintained conduction of vasoactive responses to physiological agonists in rat mesenteric small arteries likely via gap junctions and endothelial cells, providing a possible mechanism for the sustained functional and structural control of arterial networks. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

PROMISE of Coronary CT Angiography: Precise and Accurate Diagnosis and Prognosis in Coronary Artery Disease.

PubMed

Thomas, Dustin M; Branch, Kelley R; Cury, Ricardo C

2016-04-01

Coronary computed tomography angiography (CCTA) is a rapidly growing and powerful diagnostic test that offers a great deal of precision with respect to diagnosing coronary artery disease (CAD). Guideline statements for patients with stable ischemic heart disease have recommended CCTA for only a limited portion of intermediate-risk patients who have relative or absolute contraindications for exercise or vasodilator stress testing. The publication of two large, prospective randomized clinical trials, the Prospective Multicenter Imaging Study for Evaluation of Chest Pain and the Scottish Computed Tomography of the Heart Trial are likely to expand these indications. These new data from large trials, in addition to other studies, show that CCTA is highly sensitive for the detection of CAD, identifies high-risk patients for cardiac events based on extent or plaque morphology of CAD that would not be identified by other noninvasive means, and provides significantly greater diagnostic certainty for proper treatment, including referral for invasive coronary angiography with revascularization more appropriately. Superior diagnostic accuracy and prognostic data with CCTA, when compared with other functional stress tests, may result in a reduction in unnecessary downstream testing and cost savings. In addition, newer CCTA applications hold the promise of providing a complete evaluation of a patient's coronary anatomy as well as a per-vessel ischemic evaluation. This review focuses on the interval knowledge obtained from newer data on CCTA in patients with stable ischemic heart disease, primarily focusing on the contributions of the Prospective Multicenter Imaging Study for Evaluation of Chest Pain and the Scottish Computed Tomography of the Heart Trial.

Benefits of Manometer in Non-Invasive Ventilatory Support.

PubMed

Lacerda, Rodrigo Silva; de Lima, Fernando Cesar Anastácio; Bastos, Leonardo Pereira; Fardin Vinco, Anderson; Schneider, Felipe Britto Azevedo; Luduvico Coelho, Yves; Fernandes, Heitor Gomes Costa; Bacalhau, João Marcus Ramos; Bermudes, Igor Matheus Simonelli; da Silva, Claudinei Ferreira; da Silva, Luiza Paterlini; Pezato, Rogério

2017-12-01

Introduction Effective ventilation during cardiopulmonary resuscitation (CPR) is essential to reduce morbidity and mortality rates in cardiac arrest. Hyperventilation during CPR reduces the efficiency of compressions and coronary perfusion. Problem How could ventilation in CPR be optimized? The objective of this study was to evaluate non-invasive ventilator support using different devices. The study compares the regularity and intensity of non-invasive ventilation during simulated, conventional CPR and ventilatory support using three distinct ventilation devices: a standard manual resuscitator, with and without airway pressure manometer, and an automatic transport ventilator. Student's t-test was used to evaluate statistical differences between groups. P values <.05 were regarded as significant. Peak inspiratory pressure during ventilatory support and CPR was significantly increased in the group with manual resuscitator without manometer when compared with the manual resuscitator with manometer support (MS) group or automatic ventilator (AV) group. The study recommends for ventilatory support the use of a manual resuscitator equipped with MS or AVs, due to the risk of reduction in coronary perfusion pressure and iatrogenic thoracic injury during hyperventilation found using manual resuscitator without manometer. Lacerda RS , de Lima FCA , Bastos LP , Vinco AF , Schneider FBA , Coelho YL , Fernandes HGC , Bacalhau JMR , Bermudes IMS , da Silva CF , da Silva LP , Pezato R . Benefits of manometer in non-invasive ventilatory support. Prehosp Disaster Med. 2017;32(6):615-620.

Invasive cardiac procedure use and mortality among South Asian and Chinese Canadians with coronary artery disease.

PubMed

Quan, Hude; Khan, Nadia; Li, Bing; Humphries, Karin H; Faris, Peter; Galbraith, P Diane; Graham, Michelle; Knudtson, Merril L; Ghali, William A

2010-01-01

Previous studies evaluated cardiac procedure use and outcome over the short term, with relatively few Asian patients included. To determine the likelihood of undergoing percutaneous coronary intervention and coronary artery bypass grafting, and survival during 10.5 years of follow-up after coronary angiography among South Asian, Chinese and other Canadian patients. Using prospective cohort study data from two large Canadian provinces, 3061 South Asian, 1473 Chinese and 77,314 other Canadian patients with angiographically proven coronary artery disease from 1995 to 2004 were assessed, and their revascularization and mortality rates during 10.5 years of follow-up were determined. Compared with other Canadian patients, South Asian and Chinese patients were slightly less likely to undergo revascularization (riskadjusted HR 0.94, 95% CI 0.90 to 0.98 for South Asian patients; and HR 0.94, 95% CI 0.88 to 1.00 for Chinese patients). However, South Asian patients underwent coronary artery bypass grafting (HR 1.00, 95% CI 0.94 to 1.07) and Chinese patients underwent percutaneous coronary intervention (HR 0.96, 95% CI 0.89 to 1.04) as frequently as other Canadian patients. Although the 30-day mortality rate was similar across the three ethnic groups, the mortality rate in the follow-up period was significantly lower for South Asian patients (HR 0.76, 95% CI 0.61 to 0.95) and marginally lower for Chinese patients (HR 0.80, 95% CI 0.60 to 1.07) compared with other Canadian patients. South Asian and Chinese patients used revascularization slightly less but had better survival outcomes than other Canadian patients. The factors underlying the better outcomes for South Asian and Chinese patients warrant further study.

Fourth update on CT angiography of coronary stents: in vitro evaluation of 24 novel stent types.

PubMed

Hickethier, Tilman; Wenning, Justus; Doerner, Jonas; Maintz, David; Michels, Guido; Bunck, Alexander C

2017-01-01

Background Non-invasive evaluation of coronary stent patency by coronary computed tomography angiography (cCTA) remains challenging. Multiple studies showed that CT technology but also individual stent design strongly influence the assessability of coronary stents by cCTA. Purpose To expand the available data on cCTA characteristics of coronary stents by 24 novel types to help interpreting examinations of patients after stent placement and selecting which stents are suitable for assessment by cCTA. Material and Methods Twenty-four novel coronary stents (17 cobalt-chromium, six stainless-steel, one platinum-chromium) were examined in a coronary phantom. Standard cCTA parameters with stent-specific algorithms were used. Image quality was quantified for each stent using established parameters (in-stent attenuation alteration and visible lumen diameter). Results Most stents (n = 14) showed lumen visibilities of 45-55%. No severe restriction of lumen visibility (>60%) was found. The majority of stents (n = 13) caused only small intraluminal attenuation deviations and no severe alterations (>20%) were found. When grouped by manufacturing material, no significant differences were found between cobalt-chromium and stainless-steel with identical mean visible diameters (1.52 ± 0.17 mm vs. 1.52 ± 0.13 mm) and comparable attenuation alterations (35.04 ± 16.56 HU vs. 21.25 ± 14.60 HU). The only platinum-chromium stent showed a smaller visible diameter (1.23 mm) and higher attenuation alteration (41.70 HU), but was also deemed to be assessable by cCTA. Conclusion All 24 novel evaluated stents are eligible for non-invasive evaluation by cCTA without significant differences between cobalt-chromium and stainless-steel stents. This updated catalogue of CT appearances of current coronary stents may serve as reference when taking care of patients with stents in need of coronary imaging.

A machine-learning approach for computation of fractional flow reserve from coronary computed tomography.

PubMed

Itu, Lucian; Rapaka, Saikiran; Passerini, Tiziano; Georgescu, Bogdan; Schwemmer, Chris; Schoebinger, Max; Flohr, Thomas; Sharma, Puneet; Comaniciu, Dorin

2016-07-01

Fractional flow reserve (FFR) is a functional index quantifying the severity of coronary artery lesions and is clinically obtained using an invasive, catheter-based measurement. Recently, physics-based models have shown great promise in being able to noninvasively estimate FFR from patient-specific anatomical information, e.g., obtained from computed tomography scans of the heart and the coronary arteries. However, these models have high computational demand, limiting their clinical adoption. In this paper, we present a machine-learning-based model for predicting FFR as an alternative to physics-based approaches. The model is trained on a large database of synthetically generated coronary anatomies, where the target values are computed using the physics-based model. The trained model predicts FFR at each point along the centerline of the coronary tree, and its performance was assessed by comparing the predictions against physics-based computations and against invasively measured FFR for 87 patients and 125 lesions in total. Correlation between machine-learning and physics-based predictions was excellent (0.9994, P < 0.001), and no systematic bias was found in Bland-Altman analysis: mean difference was -0.00081 ± 0.0039. Invasive FFR ≤ 0.80 was found in 38 lesions out of 125 and was predicted by the machine-learning algorithm with a sensitivity of 81.6%, a specificity of 83.9%, and an accuracy of 83.2%. The correlation was 0.729 (P < 0.001). Compared with the physics-based computation, average execution time was reduced by more than 80 times, leading to near real-time assessment of FFR. Average execution time went down from 196.3 ± 78.5 s for the CFD model to ∼2.4 ± 0.44 s for the machine-learning model on a workstation with 3.4-GHz Intel i7 8-core processor. Copyright © 2016 the American Physiological Society.

Cerebral vasomotor reactivity: steady-state versus transient changes in carbon dioxide tension.

PubMed

Brothers, R Matthew; Lucas, Rebekah A I; Zhu, Yong-Sheng; Crandall, Craig G; Zhang, Rong

2014-11-01

Cerebral vasomotor reactivity (CVMR) to changes in arterial carbon dioxide tension (P aCO 2) is assessed during steady-state or transient changes in P aCO 2. This study tested the following two hypotheses: (i) that CVMR during steady-state changes differs from that during transient changes in P aCO 2; and (ii) that CVMR during rebreathing-induced hypercapnia would be blunted when preceded by a period of hyperventilation. For each hypothesis, end-tidal carbon dioxide tension (P ET , CO 2) middle cerebral artery blood velocity (CBFV), cerebrovascular conductance index (CVCI; CBFV/mean arterial pressure) and CVMR (slope of the linear regression between changes in CBFV and CVCI versus P ET , CO 2) were assessed in eight individuals. To address the first hypothesis, measurements were made during the following two conditions (randomized): (i) steady-state increases in P ET , CO 2 of 5 and 10 Torr above baseline; and (ii) rebreathing-induced transient breath-by-breath increases in P ET , CO 2. The linear regression for CBFV versus P ET , CO 2 (P = 0.65) and CVCI versus P ET , CO 2 (P = 0.44) was similar between methods; however, individual variability in CBFV or CVCI responses existed among subjects. To address the second hypothesis, the same measurements were made during the following two conditions (randomized): (i) immediately following a brief period of hypocapnia induced by hyperventilation for 1 min followed by rebreathing; and (ii) during rebreathing only. The slope of the linear regression for CBFV versus P ET , CO 2 (P < 0.01) and CVCI versus P ET , CO 2 (P < 0.01) was reduced during hyperventilation plus rebreathing relative to rebreathing only. These results indicate that cerebral vasomotor reactivity to changes in P aCO 2 is similar regardless of the employed methodology to induce changes in P aCO 2 and that hyperventilation-induced hypocapnia attenuates the cerebral vasodilatory responses during a subsequent period of rebreathing

Non-ST-segment elevation syndromes. Pharmacologic management, conservative versus early invasive approach.

PubMed

Santiago, Patrick; Tadros, Peter

2002-07-01

Many advances have been made in the treatment of acute coronary syndromes. Patients with intermediate-risk or high-risk features should receive treatment with the newer pharmacologic agents--enoxaparin, statins and, in selected cases, clopidogrel--in addition to established standard therapies (i.e., aspirin, beta-blockers, nitroglycerin, and oxygen). Use of GpIIb-IIIa inhibitors should also be strongly considered, especially in an early invasive approach. However, there is no substitute for a good physician who has the big picture and knows the individual patient in totality. This physician can best judge the dangers of the patient's acute cardiac condition against the comorbidities that may be exacerbated by revascularization procedures. The ability to weigh the risks of the patient's acute coronary syndrome against the risks of an aggressive invasive approach ultimately provides the best care for each patient.

Do we need invasive confirmation of cardiac magnetic resonance results?

PubMed

Siastała, Paweł; Kądziela, Jacek; Małek, Łukasz A; Śpiewak, Mateusz; Lech, Katarzyna; Witkowski, Adam

2017-01-01

Coronary artery revascularization is indicated in patients with documented significant obstruction of coronary blood flow associated with a large area of myocardial ischemia and/or untreatable symptoms. There are a few invasive or noninvasive methods that can provide information about the functional results of coronary artery narrowing. The application of more than one method of ischemia detection in one patient to reevaluate the indications for revascularization is used in case of atypical or no symptoms and/or borderline stenosis. To evaluate whether the results of cardiac magnetic resonance need to be reconfirmed by the invasive functional method. The hospital database revealed 25 consecutive patients with 29 stenoses who underwent cardiac magnetic resonance (CMR) and fractional flow reserve (FFR) between the end of 2010 and the end of 2014. The maximal time interval between CMR and FFR was 6 months. None of the patients experienced any clinical events or underwent procedures on coronary arteries between the studies. According to the analysis, the agreement of CMR perfusion with the FFR method was at the level of 89.7%. Assuming that FFR is the gold standard in assessing the severity of stenoses, the sensitivity of CMR perfusion was 90.9%. The percentage of non-severe lesions which were correctly identified in CMR was 88.9%. The study shows that CMR perfusion is a highly sensitive method to detect hemodynamically significant CAD and exclude nonsevere lesions. With FFR as the reference standard, the diagnostic accuracy of MR perfusion to detect ischemic CAD is high.

Do we need invasive confirmation of cardiac magnetic resonance results?

PubMed Central

Kądziela, Jacek; Małek, Łukasz A.; Śpiewak, Mateusz; Lech, Katarzyna; Witkowski, Adam

2017-01-01

Introduction Coronary artery revascularization is indicated in patients with documented significant obstruction of coronary blood flow associated with a large area of myocardial ischemia and/or untreatable symptoms. There are a few invasive or noninvasive methods that can provide information about the functional results of coronary artery narrowing. The application of more than one method of ischemia detection in one patient to reevaluate the indications for revascularization is used in case of atypical or no symptoms and/or borderline stenosis. Aim To evaluate whether the results of cardiac magnetic resonance need to be reconfirmed by the invasive functional method. Material and methods The hospital database revealed 25 consecutive patients with 29 stenoses who underwent cardiac magnetic resonance (CMR) and fractional flow reserve (FFR) between the end of 2010 and the end of 2014. The maximal time interval between CMR and FFR was 6 months. None of the patients experienced any clinical events or underwent procedures on coronary arteries between the studies. Results According to the analysis, the agreement of CMR perfusion with the FFR method was at the level of 89.7%. Assuming that FFR is the gold standard in assessing the severity of stenoses, the sensitivity of CMR perfusion was 90.9%. The percentage of non-severe lesions which were correctly identified in CMR was 88.9%. Conclusions The study shows that CMR perfusion is a highly sensitive method to detect hemodynamically significant CAD and exclude nonsevere lesions. With FFR as the reference standard, the diagnostic accuracy of MR perfusion to detect ischemic CAD is high. PMID:28344614

Improving CCTA-based lesions' hemodynamic significance assessment by accounting for partial volume modeling in automatic coronary lumen segmentation.

PubMed

Freiman, Moti; Nickisch, Hannes; Prevrhal, Sven; Schmitt, Holger; Vembar, Mani; Maurovich-Horvat, Pál; Donnelly, Patrick; Goshen, Liran

2017-03-01

The goal of this study was to assess the potential added benefit of accounting for partial volume effects (PVE) in an automatic coronary lumen segmentation algorithm that is used to determine the hemodynamic significance of a coronary artery stenosis from coronary computed tomography angiography (CCTA). Two sets of data were used in our work: (a) multivendor CCTA datasets of 18 subjects from the MICCAI 2012 challenge with automatically generated centerlines and 3 reference segmentations of 78 coronary segments and (b) additional CCTA datasets of 97 subjects with 132 coronary lesions that had invasive reference standard FFR measurements. We extracted the coronary artery centerlines for the 97 datasets by an automated software program followed by manual correction if required. An automatic machine-learning-based algorithm segmented the coronary tree with and without accounting for the PVE. We obtained CCTA-based FFR measurements using a flow simulation in the coronary trees that were generated by the automatic algorithm with and without accounting for PVE. We assessed the potential added value of PVE integration as a part of the automatic coronary lumen segmentation algorithm by means of segmentation accuracy using the MICCAI 2012 challenge framework and by means of flow simulation overall accuracy, sensitivity, specificity, negative and positive predictive values, and the receiver operated characteristic (ROC) area under the curve. We also evaluated the potential benefit of accounting for PVE in automatic segmentation for flow simulation for lesions that were diagnosed as obstructive based on CCTA which could have indicated a need for an invasive exam and revascularization. Our segmentation algorithm improves the maximal surface distance error by ~39% compared to previously published method on the 18 datasets from the MICCAI 2012 challenge with comparable Dice and mean surface distance. Results with and without accounting for PVE were comparable. In contrast

Transapical aortic valve implantation and minimally invasive off-pump bypass surgery

PubMed Central

Ahad, Samir; Baumbach, Hardy; Hill, Stephan; Franke, Ulrich F. W.

2014-01-01

Transcatheter aortic valve implantation (TAVI) has gained increasing popularity for high-risk patients with symptomatic aortic valve stenosis. A concomitant coronary artery disease leads to a complicated management and an increased perioperative risk. This case report describes the successful total arterial coronary revascularization of the left anterior descending and the left marginal branch of the circumflex artery utilizing the left internal mammary artery (LIMA) and left radial artery in off-pump technique in combination with the transapical transcatheter aortic valve implantation via minimally invasive anterolateral access in the fifth intercostal space. PMID:24221960

Does clinical pretest probability influence image quality and diagnostic accuracy in dual-source coronary CT angiography?

PubMed

Thomas, Christoph; Brodoefel, Harald; Tsiflikas, Ilias; Bruckner, Friederike; Reimann, Anja; Ketelsen, Dominik; Drosch, Tanja; Claussen, Claus D; Kopp, Andreas; Heuschmid, Martin; Burgstahler, Christof

2010-02-01

To prospectively evaluate the influence of the clinical pretest probability assessed by the Morise score onto image quality and diagnostic accuracy in coronary dual-source computed tomography angiography (DSCTA). In 61 patients, DSCTA and invasive coronary angiography were performed. Subjective image quality and accuracy for stenosis detection (>50%) of DSCTA with invasive coronary angiography as gold standard were evaluated. The influence of pretest probability onto image quality and accuracy was assessed by logistic regression and chi-square testing. Correlations of image quality and accuracy with the Morise score were determined using linear regression. Thirty-eight patients were categorized into the high, 21 into the intermediate, and 2 into the low probability group. Accuracies for the detection of significant stenoses were 0.94, 0.97, and 1.00, respectively. Logistic regressions and chi-square tests showed statistically significant correlations between Morise score and image quality (P < .0001 and P < .001) and accuracy (P = .0049 and P = .027). Linear regression revealed a cutoff Morise score for a good image quality of 16 and a cutoff for a barely diagnostic image quality beyond the upper Morise scale. Pretest probability is a weak predictor of image quality and diagnostic accuracy in coronary DSCTA. A sufficient image quality for diagnostic images can be reached with all pretest probabilities. Therefore, coronary DSCTA might be suitable also for patients with a high pretest probability. Copyright 2010 AUR. Published by Elsevier Inc. All rights reserved.

A call for randomized controlled cost-effectiveness analysis of percutaneous transluminal coronary angioplasty.

PubMed

Holly, N

1988-01-01

A rapidly evolving technology, percutaneous transluminal coronary angioplasty, is increasingly favored over bypass surgery for treating some types of coronary stenosis because of its less traumatic invasion, better recovery response, and lower initial cost. However, substantially higher failure rates in initial procedures offset PTCA's savings to an unknown extent and cloud analysis of its overall impact. Lack of randomized clinical data precludes valid cost-effectiveness comparison of the technologies at this time. Criteria for establishing valid data and evaluations of currently available data are described in this paper.

Implementation and consistency of Heart Team decision-making in complex coronary revascularisation.

PubMed

Pavlidis, Antonis N; Perera, Divaka; Karamasis, Grigoris V; Bapat, Vinayak; Young, Chris; Clapp, Brian R; Blauth, Chris; Roxburgh, James; Thomas, Martyn R; Redwood, Simon R

2016-03-01

A multidisciplinary team (MDT) approach for decision-making in patients with complex coronary artery disease (CAD) is now a class IC recommendation in the European and American guidelines for myocardial revascularisation. The aim of this study was to evaluate the implementation and consistency of Heart Team HT decision-making in complex coronary revascularisation. We prospectively evaluated the data of 399 patients derived from 51 consecutive MDT meetings held in a tertiary cardiac centre. A subset of cases was randomly selected and re-presented with the same clinical data to a panel blinded to the initial outcome, at least 6 months after the initial discussion, in order to evaluate the reproducibility of decision-making. The most common decisions included continued medical management (30%), coronary artery bypass grafting (CABG) (26%) and percutaneous coronary intervention (PCI) (17%). Other decisions, such as further assessment of symptoms or evaluation with further invasive or non-invasive tests were made in 25% of the cases. Decisions were implemented in 93% of the cases. On re-discussion of the same data (n=40) within a median period of 9 months 80% of the initial HT recommendations were successfully reproduced. The Heart Team is a robust process in the management of patient with complex CAD and decisions are largely reproducible. Although outcomes are successfully implemented in the majority of the cases, it is important that all clinical information is available during discussion and patient preference is taken into account. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Advances in non-invasive drug delivery for atherosclerotic heart disease.

PubMed

Maranhão, Raul C; Tavares, Elaine R

2015-07-01

Apart from statins, anti-platelet agents and invasive procedures, the anti-atherosclerotic medical weaponry for coronary heart disease (CHD) is scarce and only partially protects CHD patients from major adverse cardiac events. Several novel non-invasive strategies are being developed to widen the therapeutic options. Among them, drug delivery tools were tested in vivo encompassing liposomes, micelles, polymeric, metallic and lipid nanoparticles used as carriers of statins, corticosteroids, a bisphosphonate, a glitazone, anti-cancer agents, a mycotoxin, a calcium channel blocker and a compound of traditional Chinese medicine. All preparations improved parameters related to atherosclerotic lesions induced in rabbits, rats and mice and reduced neointima formation in experiments aiming to prevent post-stenting restenosis. In subjects submitted to percutaneous coronary intervention, nanoparticle formulations of paclitaxel and alendronate showed safety but are still not conclusive regarding in-stent late loss. The experience of our group in atherosclerotic rabbits treated with non-protein lipid nanoparticles associated with anti-cancer drugs such as paclitaxel, etoposide and methotrexate is summarized, and preliminary safety data in CHD patients are anticipated. Taken together, these studies show that non-invasive drug-delivery systems may become promising tools to rescue CHD patients from the risks of severe and life-threatening lesions that should be more energetically treated.

Impacts of coronary artery eccentricity on macro-recirculation and pressure drops using computational fluid dynamics

NASA Astrophysics Data System (ADS)

Poon, Eric; Thondapu, Vikas; Barlis, Peter; Ooi, Andrew

2017-11-01

Coronary artery disease remains a major cause of mortality in developed countries, and is most often due to a localized flow-limiting stenosis, or narrowing, of coronary arteries. Patients often undergo invasive procedures such as X-ray angiography and fractional flow reserve to diagnose flow-limiting lesions. Even though such diagnostic techniques are well-developed, the effects of diseased coronary segments on local flow are still poorly understood. Therefore, this study investigated the effect of irregular geometries of diseased coronary segments on the macro-recirculation and local pressure minimum regions. We employed an idealized coronary artery model with a diameter of stenosis of 75%. By systematically adjusting the eccentricity and the asymmetry of the coronary stenosis, we uncovered an increase in macro-recirculation size. Most importantly, the presence of this macro-recirculation signifies a local pressure minimum (identified by λ2 vortex identification method). This local pressure minimum has a profound effect on the pressure drops in both longitudinal and planar directions, which has implications for diagnosis and treatment of coronary artery disease. Supported by Australian Research Council LP150100233 and National Computational Infrastructure m45.

An ischemia-guided approach for risk stratification in patients with acute coronary syndromes.

PubMed

Pepine, C J

2000-12-28

The optimal management approach for patients with non-ST-segment elevation acute coronary syndromes continues to be an issue of debate. An ischemia-guided strategy appears to be effective as an alternative to either a very conservative "wait-and-see" approach or a very aggressive routine revascularization approach. The need for another approach is supported by the lack of conclusive evidence-based results favoring an early routine invasive treatment strategy. In the Thrombolysis in Myocardial Infarction (TIMI) IIIB trial, there were no differences in the incidence of death or myocardial infarction (MI) between patients treated with an early invasive approach and those treated with a conservative approach to treatment. Significantly worse outcomes were shown in patients assigned to an early invasive strategy in the Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) trial at 1-year follow-up (111 clinical events in the invasive group vs 85 in the conservative group; p = 0.05). Registry information, including that from the Organization to Assess Strategies for Ischemic Syndromes (OASIS), which included approximately 8,000 patients with unstable angina or suspected MI, has even suggested an excess hazard with a routine invasive approach. Patients with non-ST-segment elevation MI observed in the Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO)-IIB and Platelet IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trials also fared better with an ischemia-guided strategy. Even the recent FRagmin and Fast Revascularization during InStability in Coronary artery disease (FRISC II) trial investigators had to be very selective relative to eliminating high-risk patients in the first week and treating with intense anti-ischemic therapy and 5-7 days of low-molecular-weight heparin therapy to show an advantage for assigned revascularization. A careful clinical evaluation with

Menopause is associated with self-reported poor sleep quality in women without vasomotor symptoms.

PubMed

Hung, Hao-Chang; Lu, Feng-Hwa; Ou, Horng-Yih; Wu, Jin-Shang; Yang, Yi-Ching; Chang, Chih-Jen

2014-08-01

The aim of this study was to investigate the relationship between menopause and self-reported sleep quality in Chinese women without vasomotor symptoms. Cross-sectional data were collected from a decoded database of the National Cheng Kung University Hospital. Menopause was defined as absence of menses for at least 12 months or a history of hysterectomy and oophorectomy. Self-reported sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). A higher global PSQI score indicates poorer self-reported sleep quality, and a global PSQI score greater than 5 differentiates poor sleepers from good sleepers. Of the 1,088 women recruited, 353 (32.4%) were in postmenopause status. Postmenopausal women had higher mean (SD) global PSQI scores (8.0 [3.3] vs. 6.1 [2.2], P < 0.001) and a greater prevalence of poor sleepers (73.1% vs. 60.8%, P < 0.001) compared with premenopausal women. Multivariate linear regression analysis showed that menopause (β = 1.532; 95% CI, 1.135 to 1.949; P < 0.001) and snoring (β = 0.764; 95% CI, 0.299 to 1.228; P = 0.001) were positively associated with global PSQI scores, whereas long sleep duration (β = -0.791; 95% CI, -1.113 to -0.468; P < 0.001) was negatively associated with global PSQI scores. Multivariate logistic regression analyses showed that menopause (odds ratio, 1.453; 95% CI, 1.030 to 2.051; P < 0.05), long sleep duration (odds ratio, 0.545; 95% CI, 0.418 to 0.710; P < 0.001), and snoring (odds ratio, 2.022; 95% CI, 1.312 to 3.116; P = 0.001) were independent predictors of poor sleepers. Postmenopausal women without vasomotor symptoms have significantly higher global PSQI scores and a higher risk of being poor sleepers than premenopausal women. In addition, menopause and snoring are associated with an increased risk of poor self-reported sleep quality independently of cardiometabolic factors and lifestyle, whereas long sleep duration is associated with a decreased risk of poor self-reported sleep quality.

Evaluation of a Novel Laser-assisted Coronary Anastomotic Connector - the Trinity Clip - in a Porcine Off-pump Bypass Model

PubMed Central

Stecher, David; Bronkers, Glenn; Noest, Jappe O.T.; Tulleken, Cornelis A.F.; Hoefer, Imo E.; van Herwerden, Lex A.; Pasterkamp, Gerard; Buijsrogge, Marc P.

2014-01-01

To simplify and facilitate beating heart (i.e., off-pump), minimally invasive coronary artery bypass surgery, a new coronary anastomotic connector, the Trinity Clip, is developed based on the excimer laser-assisted nonocclusive anastomosis technique. The Trinity Clip connector enables simplified, sutureless, and nonocclusive connection of the graft to the coronary artery, and an excimer laser catheter laser-punches the opening of the anastomosis. Consequently, owing to the complete nonocclusive anastomosis construction, coronary conditioning (i.e., occluding or shunting) is not necessary, in contrast to the conventional anastomotic technique, hence simplifying the off-pump bypass procedure. Prior to clinical application in coronary artery bypass grafting, the safety and quality of this novel connector will be evaluated in a long-term experimental porcine off-pump coronary artery bypass (OPCAB) study. In this paper, we describe how to evaluate the coronary anastomosis in the porcine OPCAB model using various techniques to assess its quality. Representative results are summarized and visually demonstrated. PMID:25490000

Novel Non-invasive Estimation of Coronary Blood Flow using Contrast Advection in Computed Tomography Angiography

NASA Astrophysics Data System (ADS)

Eslami, Parastou; Seo, Jung-Hee; Rahsepar, Amirali; George, Richard; Lardo, Albert; Mittal, Rajat

2014-11-01

Coronary computed tomography angiography (CTA) is a promising tool for assessment of coronary stenosis and plaque burden. Recent studies have shown the presence of axial contrast concentration gradients in obstructed arteries, but the mechanism responsible for this phenomenon is not well understood. We use computational fluid dynamics to study intracoronary contrast dispersion and the correlation of concentration gradients with intracoronary blood flow and stenotic severity. Data from our CFD patient-specific simulations reveals that contrast dispersions are generated by intracoronary advection effects, and therefore, encode the coronary flow velocity. This novel method- Transluminal Attenuation Flow Encoding (TAFE) - is used to estimate the flowrate in phantom studies as well as preclinical experiments. Our results indicate a strong correlation between the values estimated from TAFE and the values measured in these experiments. The flow physics of contrast dispersion associated with TAFE will be discussed. This work is funded by grants from Coulter Foundation and Maryland Innovation Initiative. The authors have pending patents in this technology and RM and ACL have other financial interests associated with TAFE.

Hypothyroidism Is Associated With Coronary Endothelial Dysfunction in Women

PubMed Central

Sara, Jaskanwal D; Zhang, Ming; Gharib, Hossein; Lerman, Lilach O; Lerman, Amir

2015-01-01

Background Hypothyroidism is associated with an increased risk of coronary artery disease, beyond that which can be explained by its association with conventional cardiovascular risk factors. Coronary endothelial dysfunction precedes atherosclerosis, has been linked to adverse cardiovascular events, and may account for some of the increased risk in patients with hypothyroidism. The aim of this study was to determine whether there is an association between epicardial and microvascular coronary endothelial dysfunction and hypothyroidism. Methods and Results In 1388 patients (mean age 50.5 [12.3] years, 34% male) presenting with stable chest pain to Mayo Clinic, Rochester, MN for diagnostic coronary angiography, and who were found to have nonobstructive coronary artery disease (<40% stenosis), we invasively assessed coronary artery endothelial-dependent microvascular and epicardial function by evaluating changes in coronary blood flow (% Δ CBF Ach) and diameter (% Δ CAD Ach), respectively, in response to intracoronary infusions of acetylcholine. Patients were divided into 2 groups: hypothyroidism, defined as a documented history of hypothyroidism or a thyroid-stimulating hormone (TSH) >10.0 mU/mL, n=188, and euthyroidism, defined as an absence of a history of hypothyroidism in the clinical record and/or 0.3

Hypothyroidism Is Associated With Coronary Endothelial Dysfunction in Women.

PubMed

Sara, Jaskanwal D; Zhang, Ming; Gharib, Hossein; Lerman, Lilach O; Lerman, Amir

2015-07-29

Hypothyroidism is associated with an increased risk of coronary artery disease, beyond that which can be explained by its association with conventional cardiovascular risk factors. Coronary endothelial dysfunction precedes atherosclerosis, has been linked to adverse cardiovascular events, and may account for some of the increased risk in patients with hypothyroidism. The aim of this study was to determine whether there is an association between epicardial and microvascular coronary endothelial dysfunction and hypothyroidism. In 1388 patients (mean age 50.5 [12.3] years, 34% male) presenting with stable chest pain to Mayo Clinic, Rochester, MN for diagnostic coronary angiography, and who were found to have nonobstructive coronary artery disease (<40% stenosis), we invasively assessed coronary artery endothelial-dependent microvascular and epicardial function by evaluating changes in coronary blood flow (% Δ CBF Ach) and diameter (% Δ CAD Ach), respectively, in response to intracoronary infusions of acetylcholine. Patients were divided into 2 groups: hypothyroidism, defined as a documented history of hypothyroidism or a thyroid-stimulating hormone (TSH) >10.0 mU/mL, n=188, and euthyroidism, defined as an absence of a history of hypothyroidism in the clinical record and/or 0.3

The vulnerable plaque: the real villain in acute coronary syndromes.

PubMed

Liang, Michael; Puri, Aniket; Devlin, Gerard

2011-01-01

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.

Long-term survival and causes of death in patients with ST-elevation acute coronary syndrome without obstructive coronary artery disease.

PubMed

Andersson, Hedvig Bille; Pedersen, Frants; Engstrøm, Thomas; Helqvist, Steffen; Jensen, Morten Kvistholm; Jørgensen, Erik; Kelbæk, Henning; Räder, Sune Bernd Emil Werner; Saunamäki, Kari; Bates, Eric; Grande, Peer; Holmvang, Lene; Clemmensen, Peter

2018-01-07

We aimed to study survival and causes of death in patients with ST-elevation acute coronary syndrome (STE-ACS) with and without obstructive coronary artery disease (CAD). We included 4793 consecutive patients with STE-ACS triaged for acute coronary angiography at a large cardiac invasive centre (2009-2014). Of these, 88% had obstructive CAD (stenosis ≥50%), 6% had non-obstructive CAD (stenosis 1-49%), and 5% had normal coronary arteries. Patients without obstructive CAD were younger and more often female with fewer cardiovascular risk factors. Median follow-up time was 2.6 years. Compared with patients with obstructive CAD, the short-term hazard of death (≤30 days) was lower in both patients with non-obstructive CAD [hazard ratio (HR) 0.49, 95% confidence interval (CI) 0.27-0.89, P = 0.018] and normal coronary arteries (HR 0.31, 95% CI 0.11-0.83, P = 0.021). In contrast, the long-term hazard of death (>30 days) was similar in patients with non-obstructive CAD (HR 1.15, 95% CI 0.77-1.72, P = 0.487) and higher in patients with normal coronary arteries (HR 2.44, 95% CI 1.58-3.76, P < 0.001), regardless of troponin levels. Causes of death were cardiovascular in 70% of patients with obstructive CAD, 38% with non-obstructive CAD, and 32% with normal coronary arteries. Finally, patients without obstructive CAD had lower survival compared with an age and sex matched general population. STE-ACS patients without obstructive CAD had a long-term risk of death similar to or higher than patients with obstructive CAD. Causes of death were less often cardiovascular. This suggests that STE-ACS patients without obstructive CAD warrant medical attention and close follow-up. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.

Cardiovascular magnetic resonance profiling of coronary atherosclerosis: vessel wall remodelling and related myocardial blood flow alterations.

PubMed

Jahnke, Cosima; Manka, Robert; Kozerke, Sebastian; Schnackenburg, Bernhard; Gebker, Rolf; Marx, Nikolaus; Paetsch, Ingo

2014-12-01

To determine the association between coronary vessel wall morphology and haemodynamic consequences to the myocardium using a combined cardiovascular magnetic resonance (CMR) imaging protocol. Non-invasive CMR profiling of coronary atherosclerotic wall changes and related myocardial blood flow impairment has not been established yet. Sixty-three patients (45 men, 61.5 ± 10.7 years) with suspected or known coronary artery disease underwent 3.0 Tesla CMR imaging. The combined CMR protocol consisted of the following imaging modules at rest: 3D vessel wall imaging and flow measurement of the proximal right coronary artery (RCA), myocardial T2*, and first-pass perfusion imaging. During adenosine stress coronary flow, T2* and first-pass perfusion imaging were repeated. Coronary X-ray angiography classified patient groups: (i) all-smooth (n = 19); (ii) luminal irregular (diameter reduction < 30%; n = 35); and (iii) stenosed RCA (diameter reduction ≥ 50%; n = 9). The ratio of CMR-derived vessel wall area-to-lumen area significantly increased stepwise for the comparison of all-smooth vs. luminal irregular vs. stenosed RCA (1.9 ± 0.6 vs. 2.6 ± 0.6 vs. 3.6 ± 0.9, P < 0.01). Epicardial coronary flow reserve exhibited a stepwise significant decrease (3.4 ± 0.5 vs. 2.9 ± 0.7 vs. 1.7 ± 0.3, P < 0.01). On the myocardial level, stress-induced percentage gain of T2* values (ΔT2*) was significantly decreased between groups (29.2 ± 10.6 vs. 9.0 ± 9.8 vs. 2.2 ± 11.8%, P < 0.01) while perfusion reserve index decreased in the presence of stenosed RCA only (2.2 ± 0.6 vs. 2.0 ± 0.4 vs. 1.3 ± 0.3, P = ns and P < 0.01, respectively). The proposed comprehensive CMR imaging protocol provided a non-invasive approach for direct assessment of coronary vessel wall remodelling and resultant pathophysiological consequences on the level of epicardial coronary and myocardial blood flow in patients. Published on behalf of the European Society of Cardiology. All rights reserved. © The

Relationship Between Coronary Contrast-Flow Quantitative Flow Ratio and Myocardial Ischemia Assessed by SPECT MPI.

PubMed

Smit, Jeff M; Koning, Gerhard; van Rosendael, Alexander R; Dibbets-Schneider, Petra; Mertens, Bart J; Jukema, J Wouter; Delgado, Victoria; Reiber, Johan H C; Bax, Jeroen J; Scholte, Arthur J

2017-10-01

A new method has been developed to calculate fractional flow reserve (FFR) from invasive coronary angiography, the so-called "contrast-flow quantitative flow ratio (cQFR)". Recently, cQFR was compared to invasive FFR in intermediate coronary lesions showing an overall diagnostic accuracy of 85%. The purpose of this study was to investigate the relationship between cQFR and myocardial ischemia assessed by single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI). Patients who underwent SPECT MPI and coronary angiography within 3 months were included. The cQFR computation was performed offline, using dedicated software. The cQFR computation was based on 3-dimensional quantitative coronary angiography (QCA) and computational fluid dynamics. The standard 17-segment model was used to determine the vascular territories. Myocardial ischemia was defined as a summed difference score ≥2 in a vascular territory. A cQFR of ≤0.80 was considered abnormal. Two hundred and twenty-four coronary arteries were analysed in 85 patients. Overall accuracy of cQFR to detect ischemia on SPECT MPI was 90%. In multivariable analysis, cQFR was independently associated with ischemia on SPECT MPI (OR per 0.01 decrease of cQFR: 1.10; 95% CI 1.04-1.18, p = 0.002), whereas clinical and QCA parameters were not. Furthermore, cQFR showed incremental value for the detection of ischemia compared to clinical and QCA parameters (global chi square 48.7 to 62.6; p <0.001). A good relationship between cQFR and SPECT MPI was found. cQFR was independently associated with ischemia on SPECT MPI and showed incremental value to detect ischemia compared to clinical and QCA parameters.

Cerebral vasomotor reactivity: steady-state versus transient changes in carbon dioxide tension

PubMed Central

Brothers, R Matthew; Lucas, Rebekah A I; Zhu, Yong-Sheng; Crandall, Craig G; Zhang, Rong

2014-01-01

New Findings What is the central question of this study? The relationship between changes in cerebral blood flow and arterial carbon dioxide tension is used to assess cerebrovascular function. Hypercapnia is generally evoked by two methods, i.e. steady-state and transient increases in carbon dioxide tension. In some cases, the hypercapnia is immediately preceded by a period of hypocapnia. It is unknown whether the cerebrovascular response differs between these methods and whether a period of hypocapnia blunts the subsequent response to hypercapnia. What is the main finding and its importance? The cerebrovascular response is similar between steady-state and transient hypercapnia. However, hyperventilation-induced hypocapnia attenuates the cerebral vasodilatory responses during a subsequent period of rebreathing-induced hypercapnia. Cerebral vasomotor reactivity (CVMR) to changes in arterial carbon dioxide tension () is assessed during steady-state or transient changes in . This study tested the following two hypotheses: (i) that CVMR during steady-state changes differs from that during transient changes in ; and (ii) that CVMR during rebreathing-induced hypercapnia would be blunted when preceded by a period of hyperventilation. For each hypothesis, end-tidal carbon dioxide tension () middle cerebral artery blood velocity (CBFV), cerebrovascular conductance index (CVCI; CBFV/mean arterial pressure) and CVMR (slope of the linear regression between changes in CBFV and CVCI versus ) were assessed in eight individuals. To address the first hypothesis, measurements were made during the following two conditions (randomized): (i) steady-state increases in of 5 and 10 Torr above baseline; and (ii) rebreathing-induced transient breath-by-breath increases in . The linear regression for CBFV versus (P = 0.65) and CVCI versus (P = 0.44) was similar between methods; however, individual variability in CBFV or CVCI responses existed among subjects. To address the second

A novel patient-specific model to compute coronary fractional flow reserve.

PubMed

Kwon, Soon-Sung; Chung, Eui-Chul; Park, Jin-Seo; Kim, Gook-Tae; Kim, Jun-Woo; Kim, Keun-Hong; Shin, Eun-Seok; Shim, Eun Bo

2014-09-01

The fractional flow reserve (FFR) is a widely used clinical index to evaluate the functional severity of coronary stenosis. A computer simulation method based on patients' computed tomography (CT) data is a plausible non-invasive approach for computing the FFR. This method can provide a detailed solution for the stenosed coronary hemodynamics by coupling computational fluid dynamics (CFD) with the lumped parameter model (LPM) of the cardiovascular system. In this work, we have implemented a simple computational method to compute the FFR. As this method uses only coronary arteries for the CFD model and includes only the LPM of the coronary vascular system, it provides simpler boundary conditions for the coronary geometry and is computationally more efficient than existing approaches. To test the efficacy of this method, we simulated a three-dimensional straight vessel using CFD coupled with the LPM. The computed results were compared with those of the LPM. To validate this method in terms of clinically realistic geometry, a patient-specific model of stenosed coronary arteries was constructed from CT images, and the computed FFR was compared with clinically measured results. We evaluated the effect of a model aorta on the computed FFR and compared this with a model without the aorta. Computationally, the model without the aorta was more efficient than that with the aorta, reducing the CPU time required for computing a cardiac cycle to 43.4%. Copyright © 2014. Published by Elsevier Ltd.

ABSORB II randomized controlled trial: a clinical evaluation to compare the safety, efficacy, and performance of the Absorb everolimus-eluting bioresorbable vascular scaffold system against the XIENCE everolimus-eluting coronary stent system in the treatment of subjects with ischemic heart disease caused by de novo native coronary artery lesions: rationale and study design.

PubMed

Diletti, Roberto; Serruys, Patrick W; Farooq, Vasim; Sudhir, Krishnankutty; Dorange, Cecile; Miquel-Hebert, Karine; Veldhof, Susan; Rapoza, Richard; Onuma, Yoshinobu; Garcia-Garcia, Hector M; Chevalier, Bernard

2012-11-01

Currently, no data are available on the direct comparison between the Absorb everolimus-eluting bioresorbable vascular scaffold (Absorb BVS) and conventional metallic drug-eluting stents. The ABSORB II study is a randomized, active-controlled, single-blinded, multicenter clinical trial aiming to compare the second-generation Absorb BVS with the XIENCE everolimus-eluting metallic stent. Approximately 501 subjects will be enrolled on a 2:1 randomization basis (Absorb BVS/XIENCE stent) in approximately 40 investigational sites across Europe and New Zealand. Treated lesions will be up to 2 de novo native coronary artery lesions, each located in different major epicardial vessels, all with an angiographic maximal luminal diameter between 2.25 and 3.8 mm as estimated by online quantitative coronary angiography (QCA) and a lesion length of ≤48 mm. Clinical follow-up is planned at 30 and 180 days and at 1, 2, and 3 years. All subjects will undergo coronary angiography, intravascular ultrasound (IVUS) and IVUS-virtual histology at baseline (pre-device and post-device implantation) and at 2-year angiographic follow-up. The primary end point is superiority of the Absorb BVS vs XIENCE stent in terms of vasomotor reactivity of the treated segment at 2 years, defined as the QCA quantified change in the mean lumen diameter prenitrate and postnitrate administration. The coprimary end point is the noninferiority (reflex to superiority) of the QCA-derived minimum lumen diameter at 2 years postnitrate minus minimum lumen diameter postprocedure postnitrate by QCA. In addition, all subjects allocated to the Absorb BVS group will undergo multislice computed tomography imaging at 3 years. The ABSORB II randomized controlled trial (ClinicalTrials.gov NCT01425281) is designed to compare the safety, efficacy, and performance of Absorb BVS against the XIENCE everolimus-eluting stent in the treatment of de novo native coronary artery lesions. Copyright © 2012 Mosby, Inc. All rights

Relationship between changes in vasomotor symptoms and changes in menopause-specific quality of life and sleep parameters.

PubMed

Pinkerton, JoAnn V; Abraham, Lucy; Bushmakin, Andrew G; Cappelleri, Joseph C; Komm, Barry S

2016-10-01

This study characterizes and quantifies the relationship of vasomotor symptoms (VMS) of menopause with menopause-specific quality of life (MSQOL) and sleep parameters to help predict treatment outcomes and inform treatment decision-making. Data were derived from a 12-week randomized, double-blind, placebo-controlled phase 3 trial that evaluated effects of two doses of conjugated estrogens/bazedoxifene on VMS in nonhysterectomized postmenopausal women (N = 318, mean age = 53.39) experiencing at least seven moderate to severe hot flushes (HFs) per day or at least 50 per week. Repeated measures models were used to determine relationships between HF frequency and severity and outcomes on the Menopause-Specific Quality of Life questionnaire and the Medical Outcomes Study sleep scale. Sensitivity analyses were performed to check assumptions of linearity between VMS and outcomes. Frequency and severity of HFs showed approximately linear relationships with MSQOL and sleep parameters. Sensitivity analyses supported assumptions of linearity. The largest changes associated with a reduction of five HFs and a 0.5-point decrease in severity occurred in the Menopause-Specific Quality of Life vasomotor functioning domain (0.78 for number of HFs and 0.98 for severity) and the Medical Outcomes Study sleep disturbance (7.38 and 4.86) and sleep adequacy (-5.60 and -4.66) domains and the two overall sleep problems indices (SPI: 5.17 and 3.63; SPII: 5.82 and 3.83). Frequency and severity of HFs have an approximately linear relationship with MSQOL and sleep parameters-that is, improvements in HFs are associated with improvements in MSQOL and sleep. Such relationships may enable clinicians to predict changes in sleep and MSQOL expected from various VMS treatments.

The Role of Echocardiography in Coronary Artery Disease and Acute Myocardial Infarction

PubMed Central

Esmaeilzadeh, Maryam; Parsaee, Mozhgan; Maleki, Majid

2013-01-01

Echocardiography is a non-invasive diagnostic technique which provides information regarding cardiac function and hemodynamics. It is the most frequently used cardiovascular diagnostic test after electrocardiography and chest X-ray. However, in a patient with acute chest pain, Transthoracic Echocardiography is essential both for diagnosing acute coronary syndrome, zeroing on the evaluation of ventricular function and the presence of regional wall motion abnormalities, and for ruling out other etiologies of acute chest pain or dyspnea, including aortic dissection and pericardial effusion. Echocardiography is a versatile imaging modality for the management of patients with chest pain and assessment of left ventricular systolic function, diastolic function, and even myocardial and coronary perfusion and is, therefore, useful in the diagnosis and triage of patients with acute chest pain or dyspnea. This review has focused on the current applications of echocardiography in patients with coronary artery disease and myocardial infarction. PMID:23646042

Treatment of Angina and Microvascular Coronary Dysfunction

PubMed Central

Samim, Arang; Nugent, Lynn; Mehta, Puja K.; Shufelt, Chrisandra; Merz, C. Noel Bairey

2014-01-01

Opinion statement Microvascular coronary dysfunction (MCD) is an increasingly recognized cause of cardiac ischemia and angina, more commonly diagnosed in women. Patients with MCD present with the triad of persistent chest pain, ischemic changes on stress testing, and no obstructive coronary artery disease (CAD) on cardiac catheterization. Data from National Heart, Lung and Blood Institute (NHLBI)-sponsored Women’s Ischemia Syndrome Evaluation (WISE) study has shown that the diagnosis of MCD is not benign, with a 2.5% annual risk of adverse cardiac events including myocardial infarction, stroke, congestive heart failure, or death. The gold standard diagnostic test for MCD is an invasive coronary reactivity test (CRT), which uses acetylcholine, adenosine, and nitroglycerin to test the endothelial dependent and independent, microvascular and macrovascular coronary function. The CRT allows for diagnostic and treatment options as well as further risk stratifying patients for future cardiovascular events. Treatment of angina and MCD should be aimed at ischemia disease management to reduce risk of adverse cardiac events, ameliorating symptoms to improve quality of life, and to decrease the morbidity from unnecessary and repeated cardiac catheterization in patients with open coronary arteries. A comprehensive treatment approach aimed at risk factor managment, including lifestyle counseling regarding smoking cessation, nutrition and physical activity should be initiated. Current pharmacotherapy for MCD can include the treatment of microvascular endothelial dysfunction (statins, angiotensin-converting enzyme inhibitor, low dose aspirin), as well as treatment for angina and myocardial ischemia (beta blockers, calcium channel blockers, nitrates, ranolazine). Additional symptom management techniques can include tri-cyclic medication, enhanced external counterpulsation, autogenic training, and spinal cord stimulation. While our current therapies are effective in the treatment

Effect of ascorbic acid on endothelial dysfunction of epicardial coronary arteries in chronic smokers assessed by cold pressor testing.

PubMed

Schindler, T H; Magosaki, N; Jeserich, M; Olschewski, M; Nitzsche, E; Holubarsch, C; Solzbach, U; Just, H

2000-01-01

In chronic smokers there is evidence for increased formation of oxygen-derived free radicals within the vessel wall impairing endothelial function. It has been suggested that the inactivation of endothelium-derived nitric oxide by oxygen free radicals contributes to endothelial dysfunction. Hence, we tested the hypothesis that in chronic smokers the antioxidant ascorbic acid could improve abnormal endothelial function of epicardial coronary arteries. Thirty-one patients (mean age 57 +/- 9 years) referred for routine diagnostic catheterization for evaluation of chest pain and without angiographically significant coronary artery stenoses were randomly assigned to one of the study groups to assess vasomotor response of epicardial coronary arteries due to cold pressor testing (CPT) before and after intravenous infusion of 3 g of ascorbic acid or 100 ml x 0.9% saline infusion. In 6 controls (mean age 55 +/- 3 years) CPT led to a similar increase in luminal area before and after ascorbic acid administration (26.5 +/- 15.0 vs. 28.4 +/- 17.7%, p = NS). In 15 chronic smokers (mean age 55 +/- 9 years), CPT induced a decrease in the luminal area of -18.5 +/- 6.3%. This flow-dependent vasoconstriction was significantly reversed to 7.7 +/- 6.2% (p < or = 0.03) vasodilation after intravenous ascorbic acid administration. In 10 chronic smokers (mean age 57 +/- 11 years) saline infusion (placebo) did not have a significant effect on CPT-induced vasoconstriction (-12.7 +/- 5.1 vs. -13.1 +/- 5.1%, p = NS). The CPT-induced increase in luminal area in chronic smokers after ascorbic acid infusion was significant compared to controls and placebo (each p < or = 0.05). Our assessment of endothelium-independent responses to nitroglycerin revealed no significant differences between the single study groups (p = NS). In chronic smokers acute intravenous administration of ascorbic acid significantly improves CPT-induced coronary endothelium-dependent dysfunction. According to the current

Coronary Arteries

MedlinePlus

... its own vascular system, called coronary circulation. The aorta (the main blood supplier to the body) branches ... blood to the rest of the body. Tags: aorta , arteries , blood , coronary arteries , coronary artery , coronary artery ...

The Coronary Artery Disease-Reporting and Data System (CAD-RADS): Prognostic and Clinical Implications Associated With Standardized Coronary Computed Tomography Angiography Reporting.

PubMed

Xie, Joe X; Cury, Ricardo C; Leipsic, Jonathon; Crim, Matthew T; Berman, Daniel S; Gransar, Heidi; Budoff, Matthew J; Achenbach, Stephan; Ó Hartaigh, Bríain; Callister, Tracy Q; Marques, Hugo; Rubinshtein, Ronen; Al-Mallah, Mouaz H; Andreini, Daniele; Pontone, Gianluca; Cademartiri, Filippo; Maffei, Erica; Chinnaiyan, Kavitha; Raff, Gilbert; Hadamitzky, Martin; Hausleiter, Joerg; Feuchtner, Gudrun; Dunning, Allison; DeLago, Augustin; Kim, Yong-Jin; Kaufmann, Philipp A; Villines, Todd C; Chow, Benjamin J W; Hindoyan, Niree; Gomez, Millie; Lin, Fay Y; Jones, Erica; Min, James K; Shaw, Leslee J

2018-01-01

This study sought to assess clinical outcomes associated with the novel Coronary Artery Disease-Reporting and Data System (CAD-RADS) scores used to standardize coronary computed tomography angiography (CTA) reporting and their potential utility in guiding post-coronary CTA care. Clinical decision support is a major focus of health care policies aimed at improving guideline-directed care. Recently, CAD-RADS was developed to standardize coronary CTA reporting and includes clinical recommendations to facilitate patient management after coronary CTA. In the multinational CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry, 5,039 patients without known coronary artery disease (CAD) underwent coronary CTA and were stratified by CAD-RADS scores, which rank CAD stenosis severity as 0 (0%), 1 (1% to 24%), 2 (25% to 49%), 3 (50% to 69%), 4A (70% to 99% in 1 to 2 vessels), 4B (70% to 99% in 3 vessels or ≥50% left main), or 5 (100%). Kaplan-Meier and multivariable Cox models were used to estimate all-cause mortality or myocardial infarction (MI). Receiver-operating characteristic (ROC) curves were used to compare CAD-RADS to the Duke CAD Index and traditional CAD classification. Referrals to invasive coronary angiography (ICA) after coronary CTA were also assessed. Cumulative 5-year event-free survival ranged from 95.2% to 69.3% for CAD-RADS 0 to 5 (p < 0.0001). Higher scores were associated with elevations in event risk (hazard ratio: 2.46 to 6.09; p < 0.0001). The ROC curve for prediction of death or MI was 0.7052 for CAD-RADS, which was noninferior to the Duke Index (0.7073; p = 0.893) and traditional CAD classification (0.7095; p = 0.783). ICA rates were 13% for CAD-RADS 0 to 2, 66% for CAD-RADS 3, and 84% for CAD-RADS ≥4A. For CAD-RADS 3, 58% of all catheterizations occurred within the first 30 days of follow-up. In a patient subset with available medication data, 57% of CAD-RADS 3 patients who received 30

Incremental prognostic value of coronary and systemic atherosclerosis after myocardial infarction.

PubMed

Calais, Fredrik; Eriksson Östman, Maja; Hedberg, Pär; Rosenblad, Andreas; Leppert, Jerzy; Fröbert, Ole

2018-06-15

The role of systemic atherosclerosis in myocardial infarction (MI) patients is not fully understood. We investigated the incremental prognostic value of coronary and systemic atherosclerosis after acute MI by estimating extra-cardiac artery disease (ECAD) and extent of coronary atherosclerosis. The study included 544 prospective MI patients undergoing coronary angiography. For all patients, the longitudinal coronary atherosclerotic extent, expressed as Sullivan extent score (SES) was calculated. In addition, the patients underwent non-invasive screening for ECAD in the carotid, aortic, renal and lower limb. SES was found to be associated with ECAD independent of baseline clinical parameters [adjusted odds ratio (OR) 1.04 95% confidence interval (CI) 1.02-1.06, P < 0.001]. Extensive systemic atherosclerosis, defined as the combination of extensive coronary disease (SES ≥ 17) and ECAD, was associated with higher risk for all-cause mortality compared to limited systemic atherosclerosis (SES < 17 and no ECAD) (hazard ratio [HR] 2.9 95% CI 1.9-4.5, P < 0.001, adjusted for Global Registry of Acute Coronary Events risk score parameters 1.8, 95% CI 1.1-3.0, P = 0.019). The risk for the composite endpoint of cardiovascular death or hospitalization was significantly higher in patients with extensive systemic atherosclerosis compared to patients with limited systemic atherosclerosis (HR 3.1, 95% CI 2.1-4.7, P < 0.001, adjusted HR 1.9, 95% CI 1.2-3.1, P < 0.004). Visual estimation of the longitudinal coronary atherosclerotic extent at the time of MI predicts ECAD. Coexistence of extensive coronary disease and ECAD defines a group with particularly poor prognosis after MI. Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.

Quantitative assessment of myocardial blood flow in coronary artery disease by cardiovascular magnetic resonance: comparison of Fermi and distributed parameter modeling against invasive methods.

PubMed

Papanastasiou, Giorgos; Williams, Michelle C; Dweck, Marc R; Alam, Shirjel; Cooper, Annette; Mirsadraee, Saeed; Newby, David E; Semple, Scott I

2016-09-13

Mathematical modeling of perfusion cardiovascular magnetic resonance (CMR) data allows absolute quantification of myocardial blood flow and can potentially improve the diagnosis and prognostication of obstructive coronary artery disease (CAD), against the current clinical standard of visual assessments. This study compares the diagnostic performance of distributed parameter modeling (DP) against the standard Fermi model, for the detection of obstructive CAD, in per vessel against per patient analysis. A pilot cohort of 28 subjects (24 included in the final analysis) with known or suspected CAD underwent adenosine stress-rest perfusion CMR at 3T. Data were analysed using Fermi and DP modeling against invasive coronary angiography and fractional flow reserve, acquired in all subjects. Obstructive CAD was defined as luminal stenosis of ≥70 % alone, or luminal stenosis ≥50 % and fractional flow reserve ≤0.80. On ROC analysis, DP modeling outperformed the standard Fermi model, in per vessel and per patient analysis. In per patient analysis, DP modeling-derived myocardial blood flow at stress demonstrated the highest sensitivity and specificity (0.96, 0.92) in detecting obstructive CAD, against Fermi modeling (0.78, 0.88) and visual assessments (0.79, 0.88), respectively. DP modeling demonstrated consistently increased diagnostic performance against Fermi modeling and showed that it may have merit for stratifying patients with at least one vessel with obstructive CAD. Clinicaltrials.gov NCT01368237 Registered 6 of June 2011. URL: https://clinicaltrials.gov/ct2/show/NCT01368237.

International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial: Rationale and design.

PubMed

Maron, David J; Hochman, Judith S; O'Brien, Sean M; Reynolds, Harmony R; Boden, William E; Stone, Gregg W; Bangalore, Sripal; Spertus, John A; Mark, Daniel B; Alexander, Karen P; Shaw, Leslee; Berger, Jeffrey S; Ferguson, T Bruce; Williams, David O; Harrington, Robert A; Rosenberg, Yves

2018-07-01

Prior trials comparing a strategy of optimal medical therapy with or without revascularization have not shown that revascularization reduces cardiovascular events in patients with stable ischemic heart disease (SIHD). However, those trials only included participants in whom coronary anatomy was known prior to randomization and did not include sufficient numbers of participants with significant ischemia. It remains unknown whether a routine invasive approach offers incremental value over a conservative approach with catheterization reserved for failure of medical therapy in patients with moderate or severe ischemia. The ISCHEMIA trial is a National Heart, Lung, and Blood Institute supported trial, designed to compare an initial invasive or conservative treatment strategy for managing SIHD patients with moderate or severe ischemia on stress testing. Five thousand one-hundred seventy-nine participants have been randomized. Key exclusion criteria included estimated glomerular filtration rate (eGFR) <30 mL/min, recent myocardial infarction (MI), left ventricular ejection fraction <35%, left main stenosis >50%, or unacceptable angina at baseline. Most enrolled participants with normal renal function first underwent blinded coronary computed tomography angiography (CCTA) to exclude those with left main coronary artery disease (CAD) and without obstructive CAD. All randomized participants receive secondary prevention that includes lifestyle advice and pharmacologic interventions referred to as optimal medical therapy (OMT). Participants randomized to the invasive strategy underwent routine cardiac catheterization followed by revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery, when feasible, as selected by the local Heart Team to achieve optimal revascularization. Participants randomized to the conservative strategy undergo cardiac catheterization only for failure of OMT. The primary endpoint is a composite of

Coronary Computed Tomographic Angiography-Derived Fractional Flow Reserve for Therapeutic Decision Making.

PubMed

Tesche, Christian; Vliegenthart, Rozemarijn; Duguay, Taylor M; De Cecco, Carlo N; Albrecht, Moritz H; De Santis, Domenico; Langenbach, Marcel C; Varga-Szemes, Akos; Jacobs, Brian E; Jochheim, David; Baquet, Moritz; Bayer, Richard R; Litwin, Sheldon E; Hoffmann, Ellen; Steinberg, Daniel H; Schoepf, U Joseph

2017-12-15

This study investigated the performance of coronary computed tomography angiography (cCTA) with cCTA-derived fractional flow reserve (CT-FFR) compared with invasive coronary angiography (ICA) with fractional flow reserve (FFR) for therapeutic decision making in patients with suspected coronary artery disease (CAD). Seventy-four patients (62 ± 11 years, 62% men) with at least 1 coronary stenosis of ≥50% on clinically indicated dual-source cCTA, who had subsequently undergone ICA with FFR measurement, were retrospectively evaluated. CT-FFR values were computed using an on-site machine-learning algorithm to assess the functional significance of CAD. The therapeutic strategy (optimal medical therapy alone vs revascularization) and the appropriate revascularization procedure (percutaneous coronary intervention vs coronary artery bypass grafting) were selected using cCTA-CT-FFR. Thirty-six patients (49%) had a functionally significant CAD based on ICA-FFR. cCTA-CT-FFR correctly identified a functionally significant CAD and the need of revascularization in 35 of 36 patients (97%). When revascularization was deemed indicated, the same revascularization procedure (32 percutaneous coronary interventions and 3 coronary artery bypass grafting) was chosen in 35 of 35 patients (100%). Overall, identical management strategies were selected in 73 of the 74 patients (99%). cCTA-CT-FFR shows excellent performance to identify patients with and without the need for revascularization and to select the appropriate revascularization strategy. cCTA-CT-FFR as a noninvasive "one-stop shop" has the potential to change diagnostic workflows and to directly inform therapeutic decision making in patients with suspected CAD. Copyright © 2017 Elsevier Inc. All rights reserved.

Clinical outcomes of hybrid coronary revascularization versus coronary artery bypass surgery in patients with diabetes mellitus.

PubMed

Harskamp, Ralf E; Walker, Patrick F; Alexander, John H; Xian, Ying; Liberman, Henry A; de Winter, Robbert J; Vassiliades, Thomas A; Peterson, Eric D; Puskas, John D; Halkos, Michael E

2014-10-01

Hybrid coronary revascularization (HCR) involves minimally invasive left internal mammary artery to left anterior descending coronary artery grafting combined with percutaneous coronary intervention (PCI) of non-left anterior descending vessels. The safety and efficacy of HCR among diabetic patients are unknown. Patients with diabetes were included who underwent HCR at a US academic center between October 2003 and September 2013. These patients were matched 1:5 to similar patients treated with coronary artery bypass grafting (CABG) using a propensity score (PS)-matching algorithm. Conditional logistic regression and Cox regression stratified on matched pairs were performed to evaluate the association between HCR and inhospital complications, a composite measure of 30-day mortality, myocardial infarction and stroke, and up to 3-year all-cause mortality. Of 618 patients (HCR = 103; CABG = 515) in the PS-matched cohort, the 30-day composite of death, MI, or stroke after HCR and CABG was 4.9% and 3.9% (odds ratio: 1.25; 95% CI [0.47-3.33]; P = .66). Compared with CABG, HCR also had similar need for reoperation (7.6% versus 6.3%; P = .60) and renal failure (4.2% versus 4.9%; P = .76) but required less blood products (31.4% versus. 65.8%; P < .0001), lower chest tube drainage (655 mL [412-916] versus 898 mL [664-1240]; P < .0001), and shorter length of stay (<5 days: 48.3% versus 25.3%; P < .0001). Over a 3-year follow-up period, mortality was similar after HCR and CABG (12.3% versus 14.9%, hazard ratio: 0.94, 95% CI [0.47-1.88]; P = .86). Among diabetic patients, the use of HCR appears to be safe and has similar longitudinal outcomes but is associated with less blood product usage and faster recovery than conventional CABG surgery. Copyright © 2014 Mosby, Inc. All rights reserved.

Coronary microvascular dysfunction equivalent to left main coronary artery disease.

PubMed

Panç, Cafer; Kocaağa, Mehmet; Erdoğan, Onur; Sarıkaya, Remzi; Umman, Sabahattin

2017-04-01

Coronary microvascular dysfunction, also known as cardiac syndrome X, is a clinical syndrome presenting with typical angina and evidence of myocardial ischemia in the absence of flow-limiting stenosis on coronary angiography. Of patients undergoing coronary angiography due to suspected myocardial ischemia, 50% are found to have normal or near-normal coronary arteries. Described in this case report is a patient who developed hypotension and ST segment depressions during treadmill exercise test. Left main coronary artery or multivessel disease was suspected. Coronary angiography was normal, but coronary flow reserve measurement revealed severe microvascular dysfunction.

Economic analysis of the use of coronary calcium scoring as an alternative to stress ECG in the non-invasive diagnosis of coronary artery disease.

PubMed

Raman, Vivek; McWilliams, Eric T M; Holmberg, Stephen R M; Miles, Ken

2012-03-01

To conduct an economic analysis (EA) of coronary calcium scoring (CCS) using a 0 score, as alternative to stress electrocardiography (sECG) in diagnosing coronary artery disease (CAD). A decision tree was constructed to compare four strategies for investigation of suspected CAD previously assessed in the formulation of clinical guidelines for the United Kingdom (UK) to two new strategies incorporating CCS. Sensitivity (96%; 95% CI 95.4-96.4%) and specificity (40%; 95% CI 38.7-41.4%) values for CCS were derived from a meta-analysis of 10,760 patients. Other input variables were obtained from a previous EA and average prices for hospital procedures in the UK. A threshold of £30,000/Quality-adjusted Life Year (QALY) was considered cost-effective. Using net monetary benefit calculations, CCS-based strategies were found to be cost-effective compared to sECG equivalents at all assessed prevalence of CAD. Using CCS prior to myocardial perfusion scintigraphy (MPS) and catheter angiography (CA) was found to be cost-effective at pre-test probabilities (PTP) below 30%. Adoption of CCS as an alternative to sECG in investigating suspected stable angina in low PTP population (<30%) would be cost-effective. In patients with PTP of CAD >30%, proceeding to MPS or CA would be more cost-effective than performing either CCS or sECG. Coronary calcium scoring (CCS) is useful for assessing coronary artery atherosclerosis It can be performed with multi-detector CT, which is now widely available It plays a role in excluding disease in suspected stable angina Our study assesses its role in this setting as alternative to stress-ECG Adoption of CCS as an alternative to sECG could prove cost-effective.

Multiple left anterior descending coronary artery to left ventricular fistula - A case series and literature review.

PubMed

Iyer, Praneet; Yelisetti, Rishitha

2017-10-01

Coronary artery fistulas (CAFs) are found in 0.3-0.8% of patients who undergo coronary angiography. CAFs are defined as single or multiple, small or large direct communications that arise from one or more coronary arteries and enter into one of the four cardiac chambers or major vessels. We present two cases of multiple coronary artery fistulas arising from diagonal and left anterior descending (LAD) branches of left coronary artery draining into the left ventricle. In both the cases, No intervention was performed. Of the congenital fistulas, two major groups are identified: solitary CAFs or coronary artery-left ventricular multiple micro-fistulas (CALVMMFs). Noninvasive techniques such as transthoracic echocardiography, transesophageal echocardiography and magnetic resonance imaging are becoming increasingly popular for diagnosis and follow-up of CAFs. Despite the advent of these newer non-invasive modalities, coronary angiography remains the gold standard for diagnosis. Treatment of CAFs is indicated when the patients are symptomatic with left ventricular volume overload, myocardial ischemia, left ventricular dysfunction or in the presence of a large or increasing left-to-right shunt. If the fistula is small and hemodynamically insignificant, it can be managed with conservative management. Multiple left anterior descending to left ventricle (LV) fistulas are extremely rare and, as per our literature review, we noted only a few case reports of coronary artery fistulas between branches of LAD and left ventricle.

Inpatient Coronary Angiography and Revascularisation following Non-ST-Elevation Acute Coronary Syndrome in Patients with Renal Impairment: A Cohort Study Using the Myocardial Ischaemia National Audit Project

PubMed Central

Shaw, Catriona; Nitsch, Dorothea; Steenkamp, Retha; Junghans, Cornelia; Shah, Sapna; O’Donoghue, Donal; Fogarty, Damian; Weston, Clive; Sharpe, Claire C.

2014-01-01

Background International guidelines support an early invasive management strategy (including early coronary angiography and revascularisation) for non-ST-elevation acute coronary syndrome (NSTE-ACS) in patients with renal impairment. However, evidence from outside the UK suggests that this approach is underutilised. We aimed to describe practice within the NHS, and to determine whether the severity of renal dysfunction influenced the provision of angiography and modified the association between early revascularisation and survival. Methods We performed a cohort study, using multivariable logistic regression and propensity score analyses, of data from the Myocardial Ischaemia National Audit Project for patients presenting with NSTE-ACS to English or Welsh hospitals between 2008 and 2010. Findings Of 35 881 patients diagnosed with NSTE-ACS, eGFR of <60 ml/minute/1.73 m2 was present in 15 680 (43.7%). There was a stepwise decline in the odds of undergoing inpatient angiography with worsening renal dysfunction. Compared with an eGFR>90 ml/minute/1.73 m2, patients with an eGFR between 45–59 ml/minute/1.73 m2 were 33% less likely to undergo angiography (adjusted OR 0.67, 95% CI 0.55–0.81); those with an eGFR<30/minute/1.73 m2 had a 64% reduction in odds of undergoing angiography (adjusted OR 0.36, 95%CI 0.29–0.43). Of 16 646 patients who had inpatient coronary angiography, 58.5% underwent inpatient revascularisation. After adjusting for co-variables, inpatient revascularisation was associated with approximately a 30% reduction in death within 1 year compared with those managed medically after coronary angiography (adjusted OR 0.66, 95%CI 0.57–0.77), with no evidence of modification by renal function (p interaction = 0.744). Interpretation Early revascularisation may offer a similar survival benefit in patients with and without renal dysfunction, yet renal impairment is an important determinant of the provision of coronary angiography following NSTE-ACS. A

Additive value of 3T cardiovascular magnetic resonance coronary angiography for detecting coronary artery disease.

PubMed

Zhang, Lijun; Song, Xiantao; Dong, Li; Li, Jianan; Dou, Ruiyu; Fan, Zhanming; An, Jing; Li, Debiao

2018-04-30

The purpose of the work was to evaluate the incremental diagnostic value of free-breathing, contrast-enhanced, whole-heart, 3 T cardiovascular magnetic resonance coronary angiography (CE-MRCA) to stress/rest myocardial perfusion imaging (MPI) and late gadolinium enhancement (LGE) imaging for detecting coronary artery disease (CAD). Fifty-one patients with suspected CAD underwent a comprehensive cardiovascular magnetic resonance (CMR) examination (CE-MRCA, MPI, and LGE). The additive diagnostic value of MRCA to MPI and LGE was evaluated using invasive x-ray coronary angiography (XA) as the standard for defining functionally significant CAD (≥ 50% stenosis in vessels > 2 mm in diameter). 90.2% (46/51) patients (54.0 ± 11.5 years; 71.7% men) completed CE-MRCA successfully. On per-patient basis, compared to MPI/LGE alone or MPI alone, the addition of MRCA resulted in higher sensitivity (100% vs. 76.5%, p < 0.01), no change in specificity (58.3% vs. 66.7%, p = 0.6), and higher accuracy (89.1% vs 73.9%, p < 0.01) for CAD detection (prevalence = 73.9%). Compared to LGE alone, the addition of CE-MRCA resulted in higher sensitivity (97.1% vs. 41.2%, p < 0.01), inferior specificity (83.3% vs. 91.7%, p = 0.02), and higher diagnostic accuracy (93.5% vs. 54.3%, p < 0.01). The inclusion of successful free-breathing, whole-heart, 3 T CE-MRCA significantly improved the sensitivity and diagnostic accuracy as compared to MPI and LGE alone for CAD detection.

Cardiac Magnetic Resonance Imaging for the Diagnosis of Coronary Artery Disease

PubMed Central

2010-01-01

Executive Summary In July 2009, the Medical Advisory Secretariat (MAS) began work on Non-Invasive Cardiac Imaging Technologies for the Diagnosis of Coronary Artery Disease (CAD), an evidence-based review of the literature surrounding different cardiac imaging modalities to ensure that appropriate technologies are accessed by patients suspected of having CAD. This project came about when the Health Services Branch at the Ministry of Health and Long-Term Care asked MAS to provide an evidentiary platform on effectiveness and cost-effectiveness of non-invasive cardiac imaging modalities. After an initial review of the strategy and consultation with experts, MAS identified five key non-invasive cardiac imaging technologies for the diagnosis of CAD. Evidence-based analyses have been prepared for each of these five imaging modalities: cardiac magnetic resonance imaging, single photon emission computed tomography, 64-slice computed tomographic angiography, stress echocardiography, and stress echocardiography with contrast. For each technology, an economic analysis was also completed (where appropriate). A summary decision analytic model was then developed to encapsulate the data from each of these reports (available on the OHTAC and MAS website). The Non-Invasive Cardiac Imaging Technologies for the Diagnosis of Coronary Artery Disease series is made up of the following reports, which can be publicly accessed at the MAS website at: www.health.gov.on.ca/mas or at www.health.gov.on.ca/english/providers/program/mas/mas_about.html Single Photon Emission Computed Tomography for the Diagnosis of Coronary Artery Disease: An Evidence-Based Analysis Stress Echocardiography for the Diagnosis of Coronary Artery Disease: An Evidence-Based Analysis Stress Echocardiography with Contrast for the Diagnosis of Coronary Artery Disease: An Evidence-Based Analysis 64-Slice Computed Tomographic Angiography for the Diagnosis of Coronary Artery Disease: An Evidence-Based Analysis Cardiac

Stress Echocardiography for the Diagnosis of Coronary Artery Disease

PubMed Central

2010-01-01

Executive Summary In July 2009, the Medical Advisory Secretariat (MAS) began work on Non-Invasive Cardiac Imaging Technologies for the Diagnosis of Coronary Artery Disease (CAD), an evidence-based review of the literature surrounding different cardiac imaging modalities to ensure that appropriate technologies are accessed by patients suspected of having CAD. This project came about when the Health Services Branch at the Ministry of Health and Long-Term Care asked MAS to provide an evidentiary platform on effectiveness and cost-effectiveness of non-invasive cardiac imaging modalities. After an initial review of the strategy and consultation with experts, MAS identified five key non-invasive cardiac imaging technologies for the diagnosis of CAD. Evidence-based analyses have been prepared for each of these five imaging modalities: cardiac magnetic resonance imaging, single photon emission computed tomography, 64-slice computed tomographic angiography, stress echocardiography, and stress echocardiography with contrast. For each technology, an economic analysis was also completed (where appropriate). A summary decision analytic model was then developed to encapsulate the data from each of these reports (available on the OHTAC and MAS website). The Non-Invasive Cardiac Imaging Technologies for the Diagnosis of Coronary Artery Disease series is made up of the following reports, which can be publicly accessed at the MAS website at: www.health.gov.on.ca/mas"> www.health.gov.on.ca/mas or at www.health.gov.on.ca/english/providers/program/mas/mas_about.html Single Photon Emission Computed Tomography for the Diagnosis of Coronary Artery Disease: An Evidence-Based Analysis Stress Echocardiography for the Diagnosis of Coronary Artery Disease: An Evidence-Based Analysis Stress Echocardiography with Contrast for the Diagnosis of Coronary Artery Disease: An Evidence-Based Analysis 64-Slice Computed Tomographic Angiography for the Diagnosis of Coronary Artery Disease: An Evidence

Plaque disruption by coronary computed tomographic angiography in stable patients vs. acute coronary syndrome: a feasibility study.

PubMed

Bilolikar, Abhay N; Goldstein, James A; Madder, Ryan D; Chinnaiyan, Kavitha M

2016-03-01

This study was designed to determine whether coronary CT angiography (CTA) can detect features of plaque disruption in clinically stable patients and to compare lesion prevalence and features between stable patients and those with acute coronary syndrome (ACS). We retrospectively identified patients undergoing CTA, followed by invasive coronary angiography (ICA) within 60 days. Quantitative 3-vessel CTA lesion analysis was performed on all plaques ≥25% stenosis to assess total plaque volume, low attenuation plaque (LAP, <50 HU) volume, and remodelling index. Plaques were qualitatively assessed for CTA features of disruption, including ulceration and intra-plaque dye penetration (IDP). ICA was employed as a reference standard for disruption. A total of 145 (94 ACS and 51 stable) patients were identified. By CTA, plaque disruption was evident in 77.7% of ACS cases. Although more common among those with ACS, CTA also detected plaque disruption in 37.3% of clinically stable patients (P < 0.0001). Clinically stable patients commonly manifest plaques with features of disruption as determined by CTA. Though the prevalence of plaque disruption is less than patients with ACS, these findings support the concept that some clinically stable patients may harbour 'silent' disrupted plaques. These findings may have implications for detection of 'at risk' plaques and patients. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

Early versus delayed, provisional eptifibatide in acute coronary syndromes.

PubMed

Giugliano, Robert P; White, Jennifer A; Bode, Christoph; Armstrong, Paul W; Montalescot, Gilles; Lewis, Basil S; van 't Hof, Arnoud; Berdan, Lisa G; Lee, Kerry L; Strony, John T; Hildemann, Steven; Veltri, Enrico; Van de Werf, Frans; Braunwald, Eugene; Harrington, Robert A; Califf, Robert M; Newby, L Kristin

2009-05-21

Glycoprotein IIb/IIIa inhibitors are indicated in patients with acute coronary syndromes who are undergoing an invasive procedure. The optimal timing of the initiation of such therapy is unknown. We compared a strategy of early, routine administration of eptifibatide with delayed, provisional administration in 9492 patients who had acute coronary syndromes without ST-segment elevation and who were assigned to an invasive strategy. Patients were randomly assigned to receive either early eptifibatide (two boluses, each containing 180 microg per kilogram of body weight, administered 10 minutes apart, and a standard infusion > or = 12 hours before angiography) or a matching placebo infusion with provisional use of eptifibatide after angiography (delayed eptifibatide). The primary efficacy end point was a composite of death, myocardial infarction, recurrent ischemia requiring urgent revascularization, or the occurrence of a thrombotic complication during percutaneous coronary intervention that required bolus therapy opposite to the initial study-group assignment ("thrombotic bailout") at 96 hours. The key secondary end point was a composite of death or myocardial infarction within the first 30 days. Key safety end points were bleeding and the need for transfusion within the first 120 hours after randomization. The primary end point occurred in 9.3% of patients in the early-eptifibatide group and in 10.0% in the delayed-eptifibatide group (odds ratio, 0.92; 95% confidence interval [CI], 0.80 to 1.06; P=0.23). At 30 days, the rate of death or myocardial infarction was 11.2% in the early-eptifibatide group, as compared with 12.3% in the delayed-eptifibatide group (odds ratio, 0.89; 95% CI, 0.79 to 1.01; P=0.08). Patients in the early-eptifibatide group had significantly higher rates of bleeding and red-cell transfusion. There was no significant difference between the two groups in rates of severe bleeding or nonhemorrhagic serious adverse events. In patients who had acute

PET measurements of myocardial blood flow post myocardial infarction: Relationship to invasive and cardiac magnetic resonance studies and potential clinical applications.

PubMed

Gewirtz, Henry

2017-12-01

This review focuses on clinical studies concerning assessment of coronary microvascular and conduit vessel function primarily in the context of acute and sub acute myocardial infarction (MI). The ability of quantitative PET measurements of myocardial blood flow (MBF) to delineate underlying pathophysiology and assist in clinical decision making in this setting is discussed. Likewise, considered are physiological metrics fractional flow reserve, coronary flow reserve, index of microvascular resistance (FFR, CFR, IMR) obtained from invasive studies performed in the cardiac catheterization laboratory, typically at the time of PCI for MI. The role both of invasive studies and cardiac magnetic resonance (CMR) imaging in assessing microvascular function, a key determinant of prognosis, is reviewed. The interface between quantitative PET MBF measurements and underlying pathophysiology, as demonstrated both by invasive and CMR methodology, is discussed in the context of optimal interpretation of the quantitative PET MBF exam and its potential clinical applications.

Identification of the State of Maximal Hyperemia in the Assessment of Coronary Fractional Flow Reserve Using Non-Invasive Electrical Velocimetry.

PubMed

Murasawa, Takahide; Takahashi, Masao; Myojo, Masahiro; Kiyosue, Arihiro; Oguri, Atsushi; Ando, Jiro; Komuro, Issei

2017-05-31

Previous research revealed that, in patients with coronary pressure-derived fractional flow reserve (FFR) in the 'grey zone' (0.75-0.85), repeated FFR assessments sometimes yield conflicting results. One of the causes of the fluctuations in FFR values around the grey zone may be imprecise identification of the point where maximal hyperemia is achieved. Identification of the state of maximal hyperemia during assessment of FFR can be challenging. This study aimed to determine whether non-invasive electrical velocimetry (EV) can be used to identify the state of maximal hyperemia.Stroke volume (SV), SV variation (SVV), and systemic vascular resistance index (SVRI) were determined by EV in 15 patients who underwent FFR assessment. Time intervals from initiation of adenosine infusion to achieving maximal hyperemia (time mFRR ), as well as to achieving maximal cardiac output (CO), SV, SVV, and SVRI (time mCO , time mSV , time mSVV , and time mSVRI , respectively), were determined. Time mCO and time mSVV were closer to time mFRR than other values (time mSVV /time mFRR versus time mSVRI /time mFRR = 1.03 ± 0.2 versus 1.36 ± 0.4, P < 0.05). The maximum of SV was difficult to determine owing to considerable variations, but the maximum of SVV was clearly recognized. Time mCO and time mSVV were significantly correlated with time mFFR , with time mSVV showing a stronger correlation than time mSV (time mSVV : r = 0.92, P < 0.01; time mCO : r = 0.80, P < 0.01).Maximal SVV is reached close to maximal hyperemia. Monitoring of SVV with non-invasive EV during FFR assessment can help identify the state of maximal hyperemia.

Pooled diagnostic accuracy of resting distal to aortic coronary pressure referenced to fractional flow reserve: The importance of resting coronary physiology.

PubMed

Maini, Rohit; Moscona, John; Sidhu, Gursukhman; Katigbak, Paul; Fernandez, Camilo; Irimpen, Anand; Mogabgab, Owen; Ward, Charisse; Samson, Rohan; LeJemtel, Thierry

2018-04-29

Both resting and hyperemic physiologic methods to guide coronary revascularization improve cardiovascular outcomes compared with angiographic guidance alone. Fractional flow reserve (FFR) remains underutilized due to concerns regarding hyperemia, prompting study of resting distal to aortic coronary pressure (Pd/Pa). Pd/Pa is a vasodilator-free resting index unlike FFR. While Pd/Pa is similar to another resting index, instantaneous wave-free ratio (iFR), it is a whole-cycle measurement not limited to the wave-free diastolic period. Pd/Pa is not validated clinically although multiple accuracy studies have been performed. Our meta-analysis examines the overall diagnostic accuracy of Pd/Pa referenced to FFR, the accepted invasive standard of ischemia. We searched PubMed, EMBASE, Central, ProQuest, and Web of Science databases for full text articles published through August 9, 2017 addressing the diagnostic accuracy of Pd/Pa referenced to FFR < 0.80. The following keywords were used: "distal coronary artery pressure" OR "Pd/Pa" AND "fractional flow reserve" OR "FFR." In total, 14 studies comprising 7004 lesions were identified. Pooled diagnostic accuracy estimates of Pd/Pa versus FFR < 0.80 were: sensitivity, 0.77 (95% CI, 0.75-0.78); specificity, 0.82 (0.81-0.83); positive likelihood ratio, 4.7 (3.3-6.6); negative likelihood ratio, 0.29 (0.24-0.34); diagnostic odds ratio, 18.1 (14.4-22.6); area under the summary receiver-operating characteristic curve of 0.88; and diagnostic accuracy of 0.80 (0.76-0.83). Pd/Pa shows adequate agreement with FFR as a resting index of coronary stenosis severity without the undesired effects and cost of hyperemic agents. Pd/Pa has the potential to guide coronary revascularization with easier application and availability compared with iFR and FFR. © 2018, Wiley Periodicals, Inc.

Use of mindfulness, meditation and relaxation to treat vasomotor symptoms.

PubMed

Goldstein, K M; Shepherd-Banigan, M; Coeytaux, R R; McDuffie, J R; Adam, S; Befus, D; Goode, A P; Kosinski, A S; Masilamani, V; Williams, J W

2017-04-01

Postmenopausal women with bothersome vasomotor symptoms (VMS) often seek alternatives to hormone-based treatment due to medication risks or personal preference. We sought to identify the effects of meditation, mindfulness, hypnosis and relaxation on VMS and health-related quality of life in perimenopausal and postmenopausal women. To do this, we conducted an umbrella review supplemented by new randomized, controlled trials (RCTs) published since the most recent good-quality systematic review for eligible interventions. We searched MEDLINE and the Cochrane Database of Systematic Reviews, PubMed, EMBASE, CINAHL and the Allied and Complementary Medicine Databases. We identified five systematic reviews and six new RCTs that met eligibility criteria. In a new meta-analysis examining four RCTs comparing paced respiration with a control group, we found that paced respiration is not associated with a statistically significant decrease in VMS frequency (standardized mean difference (SMD) 0.04, 95% confidence interval (CI) -0.73 to 0.82, I 2  =   56.6%, three trials) or severity (SMD 0.06, 95% CI -0.69 to 0.80; I 2  =   65.1%, three trials). There was not sufficient new information to conduct meta-analyses that examined the effect of mindfulness or hypnosis on our outcomes of interest. No effect on VMS or quality of life was found between various relaxation or mindfulness interventions.

Coronary angiography

MedlinePlus

... Angiogram - coronary; Coronary artery disease - angiography; CAD - angiography; Angina - angiography; Heart disease - angiography ... Coronary angiography may be done if: You have angina for the first time. Your angina that is ...

National variation in coronary angiography rates and timing after an acute coronary syndrome in New Zealand (ANZACS-QI 6).

PubMed

Williams, Michael J A; Harding, Scott A; Devlin, Gerard; Nunn, Chris; El-Jack, Sief; Scott, Tony; Lee, Mildred; Kerr, Andrew J

2016-01-08

The New Zealand Cardiac Clinical Network and the Ministry of Health recommend a "3-day door-to-catheter target" for acute coronary syndromes (ACS) admissions, requiring that at least 70% of ACS patients referred for invasive coronary angiography (ICA) undergo this within 3 days of hospital admission. We assessed the variability in use of ICA, timing of ICA, and duration of hospital admission across New Zealand District Health Boards (DHBs). All patients admitted to all New Zealand public hospitals with suspected ACS undergoing ICA over 1 year ending November 2014 had demographic, risk factor, and diagnostic data collected prospectively using the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. Complete datasets were available in 7,988 (98.4%) patients. DHBs were categorised as those able to perform percutaneous coronary intervention on-site (intervention-capable) or not. There was a near two-fold variation between DHBs in the age standardised rate (ASR) of ICA ranging from 16.8 per 10,000 to 34.1 per 10,000 population (New Zealand rate; 27.9 per 10,000). Patients in intervention-capable DHBs had a 30% higher ASR of ICA. The proportion of ACS patients meeting the 3-day target ranged from 56.7% to 92.9% (New Zealand; 76.4%). Those in intervention-capable DHBs were more likely to meet the target (78.7% vs 68.0%, p<0.0001) and spent 0.84 days (p<.0001) less in hospital. There is a considerable variation in the rate and timing of ICA in New Zealand. Patients with ACS admitted to DHBs without interventional-capability are disadvantaged. New initiatives to correct this discrepancy are needed.

Validation of high temporal resolution spiral phase velocity mapping of temporal patterns of left and right coronary artery blood flow against Doppler guidewire.

PubMed

Keegan, Jennifer; Raphael, Claire E; Parker, Kim; Simpson, Robin M; Strain, Stephen; de Silva, Ranil; Di Mario, Carlo; Collinson, Julian; Stables, Rod H; Wage, Ricardo; Drivas, Peter; Sugathapala, Malindie; Prasad, Sanjay K; Firmin, David N

2015-10-02

Temporal patterns of coronary blood flow velocity can provide important information on disease state and are currently assessed invasively using a Doppler guidewire. A non-invasive alternative would be beneficial as it would allow study of a wider patient population and serial scanning. A retrospectively-gated breath-hold spiral phase velocity mapping sequence (TR 19 ms) was developed at 3 Tesla. Velocity maps were acquired in 8 proximal right and 15 proximal left coronary arteries of 18 subjects who had previously had a Doppler guidewire study at the time of coronary angiography. Cardiovascular magnetic resonance (CMR) velocity-time curves were processed semi-automatically and compared with corresponding invasive Doppler data. When corrected for differences in heart rate between the two studies, CMR mean velocity through the cardiac cycle, peak systolic velocity (PSV) and peak diastolic velocity (PDV) were approximately 40 % of the peak Doppler values with a moderate - good linear relationship between the two techniques (R(2): 0.57, 0.64 and 0.79 respectively). CMR values of PDV/PSV showed a strong linear relationship with Doppler values with a slope close to unity (0.89 and 0.90 for right and left arteries respectively). In individual vessels, plots of CMR velocities at all cardiac phases against corresponding Doppler velocities showed a consistent linear relationship between the two with high R(2) values (mean +/-SD: 0.79 +/-.13). High temporal resolution breath-hold spiral phase velocity mapping underestimates absolute values of coronary flow velocity but allows accurate assessment of the temporal patterns of blood flow.

What do Polish interventional cardiologists know about indications and qualification for recanalisation of chronic total coronary artery occlusions?

PubMed

Bryniarski, Krzysztof L; Zabojszcz, Michał; Dębski, Grzegorz; Marchewka, Jakub; Legutko, Jacek; Jankowski, Piotr; Siudak, Zbigniew; Żmudka, Krzysztof; Dudek, Dariusz; Bryniarski, Leszek

2015-01-01

Chronic total occlusions (CTO) are diagnosed in about 20% of patients with significant coronary artery disease. A disproportion between the high prevalence of CTOs and low rate of invasive treatment still exists. Technical difficulties, clinical uncertainties whether patients benefit from recanalisation, and a lack of knowledge of CTO may be responsible for this fact. To assess the knowledge of coronary arteries CTO among Polish interventional cardiologists. A self-designed questionnaire was used during two major Polish invasive cardiology workshops held in 2014. The study included 113 physicians, mostly cardiologists certified as independent operators. Average self-declared efficacy of CTO recanalisation was 63.5%. Most of the respondents agreed that the operator involved in the CTO recanalisation program should perform at least 30-50 procedures per year. Only 67% stated that before CTO revascularisation the evaluation of myocardial viability should be performed with dobutamine stress echocardiography as a preferred test. One third of the physicians agreed that CTO percutaneous coronary intervention (PCI) should not be performed directly after diagnostic angiography, and 51.5% believed that in patients with multi-vessel coronary artery disease PCI of CTO should be performed first. Multi-slice spiral computed tomography during the qualification and planning of the CTO revascularisation, in the opinion of 91% of the responders, should not be used before each procedure but could be useful in selected cases. Polish interventional cardiologists remains in compliance with current opinions about recanalisation of chronic coronary artery occlusions and the consensus of the EuroCTO Club, but there is still an unceasing need for further education and promotion of knowledge about CTOs.

Narrowing of the Coronary Sinus: A Device-Based Therapy for Persistent Angina Pectoris.

PubMed

Konigstein, Maayan; Verheye, Stefan; Jolicœur, E Marc; Banai, Shmuel

2016-01-01

Alongside the remarkable advances in medical and invasive therapies for the treatment of ischemic heart disease, an increasing number of patients with advanced coronary artery disease unsuitable for revascularization continue to suffer from angina pectoris despite optimal medical therapy. Patients with chronic angina have poor quality of life and increased levels of anxiety and depression. A considerable number of innovative therapeutic modalities for the treatment of chronic angina have been investigated over the years; however, none of these therapeutic options has become a standard of care, and none are widely utilized. Current treatment options for refractory angina focus on medical therapy and secondary risk factor modification. Interventions to create increased pressure in the coronary sinus may alleviate myocardial ischemia by forcing redistribution of coronary blood flow from the less ischemic subepicardium to the more ischemic subendocardium, thus relieving symptoms of ischemia. Percutaneous, transvenous implantation of a balloon expandable, hourglass-shaped, stainless steel mesh in the coronary sinus to create a fixed focal narrowing and to increase backwards pressure, may serve as a new device-based therapy destined for the treatment of refractory angina pectoris.

Fractional Flow Reserve and Coronary Computed Tomographic Angiography: A Review and Critical Analysis.

PubMed

Hecht, Harvey S; Narula, Jagat; Fearon, William F

2016-07-08

Invasive fractional flow reserve (FFR) is now the gold standard for intervention. Noninvasive functional imaging analyses derived from coronary computed tomographic angiography (CTA) offer alternatives for evaluating lesion-specific ischemia. CT-FFR, CT myocardial perfusion imaging, and transluminal attenuation gradient/corrected contrast opacification have been studied using invasive FFR as the gold standard. CT-FFR has demonstrated significant improvement in specificity and positive predictive value compared with CTA alone for predicting FFR of ≤0.80, as well as decreasing the frequency of nonobstructive invasive coronary angiography. High-risk plaque characteristics have also been strongly implicated in abnormal FFR. Myocardial computed tomographic perfusion is an alternative method with promising results; it involves more radiation and contrast. Transluminal attenuation gradient/corrected contrast opacification is more controversial and may be more related to vessel diameter than stenosis. Important considerations remain: (1) improvement of CTA quality to decrease unevaluable studies, (2) is the diagnostic accuracy of CT-FFR sufficient? (3) can CT-FFR guide intervention without invasive FFR confirmation? (4) what are the long-term outcomes of CT-FFR-guided treatment and how do they compare with other functional imaging-guided paradigms? (5) what degree of stenosis on CTA warrants CT-FFR? (6) how should high-risk plaque be incorporated into treatment decisions? (7) how will CT-FFR influence other functional imaging test utilization, and what will be the effect on the practice of cardiology? (8) will a workstation-based CT-FFR be mandatory? Rapid progress to date suggests that CTA-based lesion-specific ischemia will be the gatekeeper to the cardiac catheterization laboratory and will transform the world of intervention. © 2016 American Heart Association, Inc.

Associations of Menopausal Vasomotor Symptoms with Fracture Incidence

PubMed Central

Aragaki, Aaron; Cauley, Jane A.; Manson, JoAnn E.; LeBlanc, Erin; Wallace, Robert; Wactawski-Wende, Jean; LaCroix, Andrea; O'Sullivan, Mary Jo; Vitolins, Mara; Watts, Nelson B.

2015-01-01

Context: Vasomotor symptoms (VMS) are common. Whether VMS are associated with fracture incidence or bone mineral density (BMD) levels is unknown. Objective: This study aimed to examine associations of baseline VMS with fracture incidence and BMD. Design: This was a prospective observational study with mean (SD) followup of 8.2 (1.7) years (1993–2005). Setting: Forty United States clinical centers. Participants: We examined data from Women's Health Initiative Clinical Trial participants (n = 23 573) age 50–79 years not using menopausal hormone therapy, and 4,867 participants of the BMD sub-study. Interventions: None. Main Outcome Measures: We measured baseline VMS, incident adjudicated fractures, and BMD (baseline, annual visits 1, 3, 6, and 9). Results: After adjustment for baseline age, body mass index, race/ethnicity, smoking, and education, the hazard ratio for hip fracture among women with baseline moderate/severe VMS (vs no VMS) was 1.78 (95% confidence interval [CI], 1.20–2.64; P = .01). There was no association between VMS and vertebral fracture. VMS severity was inversely associated with BMD during followup (P = .004 for femoral neck, P = .045 for lumbar spine). In repeated measures models, compared with women who reported no VMS, women with moderate/severe VMS had 0.015 g/cm2 lower femoral neck BMD (95% CI, −0.025–−0.005) and 0.016 g/cm2 lower lumbar spine BMD (95% CI, −0.032–−0.004). Conclusions: Women with moderate/severe VMS have lower BMD and increased hip fracture rates. Elucidation of the biological mechanisms underlying these associations may inform the design of preventive strategies for at-risk women prior to occurrence of fracture. PMID:25522264

[Relationship between coronary tortuosity and coronary microvascular disease].

PubMed

Wang, Z Y; Wang, Y B; Hao, G Z; Jiang, Y F; Gu, X S; Fan, W Z; Gong, Q; Wang, Q; Fu, X H

2018-05-24

Objective: To explore the relationship between coronary tortuosity and coronary microvascular disease (CMVD). Methods: Patients with typical angina symptoms and without serious coronary artery stenosis by coronary angiography were enrolled from June 2014 to December 2016, and CMVD was diagnosed by single photon emission tomography (SPECT). According to the SPECT results, patients were divided to the CMVD group and non-CMVD group. The baseline clinical characteristics, results of coronary angiography were compared between the two groups. The logistic analysis was used to analyze the relationship between coronary tortuosity and CMVD. Result: A total of 117 cases were enrolled, with 69 cases in the CMVD group and 48 cases in the non-CMVD group. No differences were found in gender distribution, age, hypertension, lipid abnormality, hyperuricemia and uses of statins between the two groups (all P >0.05). Incidence of diabetes (78.26%(54/69) vs. 35.42% (17/48) , P <0.05), hs-CRP ((4.29±2.15)mmol/L vs. (2.63±1.20)mmol/L, P <0.001), LDL-C ((2.98±0.96)mmol/L vs. (2.52±0.83)mmol/L, P= 0.008) and homocysteine ((13.7±5.61)mmol/L vs. (11.5±4.38)mmol/L, P= 0.025) levels were higher in the CMVD group than in the non-CMVD group. The data derived from echocardiographic examination were similar between the two groups. The Corrected TIMI frame counts were higher in the CMVD group than in non-CMVD group (LAD: 31.56±4.92 vs. 27.31±3.75, LCX: 29.47±4.18 vs. 26.62±3.19, RCA: 29.09±5.05 vs. 26.24±3.28, all P <0.001). The incidences of coronary atherosclerosis (76.81% (53/69) vs. 27.08% (13/48) , P <0.001) and coronary tortuosity ( (60.87% (42/69) vs. 33.33% (16/48) , P= 0.035) were also higher in the CMVD group than in non-CMVD group. Logistic analysis found that coronary tortuosity ( OR= 6.111, 95% CI 2.707-13.794, P <0.001), diabetes ( OR= 6.565, 95% CI 2.883-14.948, P <0.001) and coronary atherosclerosis ( OR= 8.918, 95% CI 3.822-20.808, P <0.001) were independent risk

The incidence of coronary anomalies on routine coronary computed tomography scans

PubMed Central

Karabay, Kanber Ocal; Yildiz, Abdulmelik; Bagirtan, Bayram; Geceer, Gurkan; Uysal, Ender

2013-01-01

Summary Objective This study aimed to assess the incidence of coronary anomalies using 64-multi-slice coronary computed tomography (MSCT). Methods The diagnostic MSCT scans of 745 consecutive patients were reviewed. Results The incidence of coronary anomalies was 4.96%. The detected coronary anomalies included the conus artery originating separately from the right coronary sinus (RCS) (n = 8, 1.07%), absence of the left main artery (n = 7, 0.93%), a superior right coronary artery (RCA) (n = 7, 0.93%), the circumflex artery (CFX) arising from the RCS (n = 4, 0.53%), the CFX originating from the RCA (n = 2, 0.26%), a posterior RCA (n = 1, 0.13%), a coronary fistula from the left anterior descending artery and RCA to the pulmonary artery (n = 1, 0.13%), and a coronary aneurysm (n = 1, 0.13%). Conclusions This study indicated that MSCT can be used to detect common coronary anomalies, and shows it has the potential to aid cardiologists and cardiac surgeons by revealing the origin and course of the coronary vessels. PMID:24042853

The C-Port Distal Coronary Anastomotic Device Is Comparable With a Hand-Sewn Anastomosis: Human Histological Case Study.

PubMed

Balkhy, Husam H; Nisivaco, Sarah M; Husain, Aliya N; Jeevanandam, Valluvan; Arif, Quidsia

Coronary artery bypass surgery is most commonly performed using a hand-sewn technique with a continuous monofilament suture. The C-Port distal anastomotic device is a miniature stapler designed to create an arteriotomy and attach the graft to the coronary artery all in one step. It is the only distal coronary anastomotic device currently approved for clinical use and can be useful in facilitating less invasive coronary surgery. This report examines the histological attributes of such an anastomosis in a patient who underwent heart transplantation approximately 1 year after robotic totally endoscopic stapled coronary bypass using the C-Port anastomotic device. There have been no previous reports of histological examination of this type of bypass graft in humans in the literature. We found that the C-Port single-shot stapled coronary anastomotic device had a similar histological appearance to a traditional hand-sewn technique using monofilament suture. The amount of inflammation around the anastomosis using the two techniques was found to be comparable in this histological case study in an explanted human heart. There was no evidence of increased neointimal hyperplasia. These findings add to the already known equivalent clinical patency rates of the C-Port device in coronary bypass procedures.

MF-101, an estrogen receptor beta agonist for the treatment of vasomotor symptoms in peri- and postmenopausal women.

PubMed

Stovall, Dale W; Pinkerton, Joann V

2009-04-01

During peri- and postmenopausal stages, the majority of women experience moderate-to-severe vasomotor symptoms, such as hot flashes and night sweats, that interfere with sleep and reduce quality of life. Estrogen alone or in combination with a progestagen has been the standard therapy for such vasomotor symptoms; however, this therapeutic regimen is associated with severe side effects, such as breast cancer or cardiovascular events. To provide a better treatment option for menopausal women, Bionovo Inc is developing the estrogen receptor (ER)beta-selective agonist MF-101. Selective ER agonists can stimulate either ERalpha or ERbeta and induce tissue-specific estrogen-like effects, thus providing a safer alternative to conventional hormone therapy. MF-101 is derived from 22 herbs that are traditionally used in Chinese medicine for the treatment of menopausal symptoms. MF-101 did not promote the growth of breast cancer cells or stimulate uterine growth in preclinical studies and, in a phase II trial, was demonstrated to be safe and more effective in reducing the frequency and severity of hot flashes in postmenopausal women compared with placebo. To confirm the safety and efficacy of MF-101, larger phase III trials were planned for 2009. Although MF-101 appears to be a promising therapeutic, the herbal composition of the drug may be a disadvantage, because of the increased risk of causing allergic reactions in the general population. Studies with the MF-101-isolated active compounds liquiritigen and chalcone demonstrated selectivity for ERbeta, with no induction of proliferative events. If these isolates were demonstrated to be as effective and safe in clinical trials as preliminary data suggest regarding MF-101, these compounds could change the way clinicians treat menopause-associated symptoms.

Impact of Coronary Calcification on Clinical Management in Patients With Acute Chest Pain

PubMed Central

Bittner, Daniel O.; Mayrhofer, Thomas; Bamberg, Fabian; Hallett, Travis R.; Janjua, Sumbal; Addison, Daniel; Nagurney, John T.; Udelson, James E.; Lu, Michael T.; Truong, Quynh A.; Woodard, Pamela K.; Hollander, Judd E.; Miller, Chadwick; Chang, Anna Marie; Singh, Harjit; Litt, Harold; Hoffmann, Udo; Ferencik, Maros

2018-01-01

Background Coronary artery calcification (CAC) may impair diagnostic assessment of coronary computed tomography angiography (CTA). We determined whether CAC affects efficiency of coronary CTA in patients with suspected acute coronary syndrome (ACS). Methods and Results This is a pooled analysis of ACRIN-PA-4005 and ROMICAT-II trial comparing an initial coronary CTA strategy to standard of care in acute chest pain patients. In the CTA arms, we investigated appropriateness of downstream testing, cost and diagnostic yield to identify patients with obstructive coronary artery disease (CAD) on subsequent invasive coronary angiography (ICA) across CAC score strata (Agatston score: 0, >0–10, >10–100, >100–400, >400). Out of 1,234 patients (mean age 51±8.8 years), 80 (6.5%) had obstructive CAD (≥70% stenosis), and 68 (5.5%) had ACS. Prevalence of obstructive CAD (1% to 64%), ACS (1% to 44%), downstream testing (4% to 72%), total (2337 US$ to 8484 US$) and diagnostic cost (2310 US$ to 6678 US$) increased across CAC strata (p<0.001). As the increase in testing and cost were lower than the increase of ACS rate in patients with CAC>400, cost to diagnose one ACS was lowest in this group (19,283 US$ vs. 464,399 US$) as compared to patients without CAC. The diagnostic yield of ICA was highest in patients with CAC>400 (87% vs. 38%). Conclusion Downstream testing, total and diagnostic cost increased with increasing CAC, but were found to be appropriate, as obstructive CAD and ACS were more prevalent in patients with high CAC. In patients with acute chest pain undergoing coronary CTA, cost efficient testing and excellent diagnostic yield can be achieved even with high CAC burden. Clinical Trial Registration Information URL: https://clinicaltrials.gov. Unique identifier: NCT01084239 and NCT00933400. PMID:28487318

A novel ultrafast-low-dose computed tomography protocol allows concomitant coronary artery evaluation and lung cancer screening.

PubMed

Gaudio, Carlo; Petriello, Gennaro; Pelliccia, Francesco; Tanzilli, Alessandra; Bandiera, Alberto; Tanzilli, Gaetano; Barillà, Francesco; Paravati, Vincenzo; Pellegrini, Massimo; Mangieri, Enrico; Barillari, Paolo

2018-05-08

Cardiac computed tomography (CT) is often performed in patients who are at high risk for lung cancer in whom screening is currently recommended. We tested diagnostic ability and radiation exposure of a novel ultra-low-dose CT protocol that allows concomitant coronary artery evaluation and lung screening. We studied 30 current or former heavy smoker subjects with suspected or known coronary artery disease who underwent CT assessment of both coronary arteries and thoracic area (Revolution CT, General Electric). A new ultrafast-low-dose single protocol was used for ECG-gated helical acquisition of the heart and the whole chest. A single IV iodine bolus (70-90 ml) was used. All patients with CT evidence of coronary stenosis underwent also invasive coronary angiography. All the coronary segments were assessable in 28/30 (93%) patients. Only 8 coronary segments were not assessable in 2 patients due to motion artefacts (assessability: 98%; 477/485 segments). In the assessable segments, 20/21 significant stenoses (> 70% reduction of vessel diameter) were correctly diagnosed. Pulmonary nodules were detected in 5 patients, thus requiring to schedule follow-up surveillance CT thorax. Effective dose was 1.3 ± 0.9 mSv (range: 0.8-3.2 mSv). Noteworthy, no contrast or radiation dose increment was required with the new protocol as compared to conventional coronary CT protocol. The novel ultrafast-low-dose CT protocol allows lung cancer screening at time of coronary artery evaluation. The new approach might enhance the cost-effectiveness of coronary CT in heavy smokers with suspected or known coronary artery disease.

Dose comparisons of clopidogrel and aspirin in acute coronary syndromes.

PubMed

Mehta, Shamir R; Bassand, Jean-Pierre; Chrolavicius, Susan; Diaz, Rafael; Eikelboom, John W; Fox, Keith A A; Granger, Christopher B; Jolly, Sanjit; Joyner, Campbell D; Rupprecht, Hans-Jurgen; Widimsky, Petr; Afzal, Rizwan; Pogue, Janice; Yusuf, Salim

2010-09-02

Clopidogrel and aspirin are widely used for patients with acute coronary syndromes and those undergoing percutaneous coronary intervention (PCI). However, evidence-based guidelines for dosing have not been established for either agent. We randomly assigned, in a 2-by-2 factorial design, 25,086 patients with an acute coronary syndrome who were referred for an invasive strategy to either double-dose clopidogrel (a 600-mg loading dose on day 1, followed by 150 mg daily for 6 days and 75 mg daily thereafter) or standard-dose clopidogrel (a 300-mg loading dose and 75 mg daily thereafter) and either higher-dose aspirin (300 to 325 mg daily) or lower-dose aspirin (75 to 100 mg daily). The primary outcome was cardiovascular death, myocardial infarction, or stroke at 30 days. The primary outcome occurred in 4.2% of patients assigned to double-dose clopidogrel as compared with 4.4% assigned to standard-dose clopidogrel (hazard ratio, 0.94; 95% confidence interval [CI], 0.83 to 1.06; P=0.30). Major bleeding occurred in 2.5% of patients in the double-dose group and in 2.0% in the standard-dose group (hazard ratio, 1.24; 95% CI, 1.05 to 1.46; P=0.01). Double-dose clopidogrel was associated with a significant reduction in the secondary outcome of stent thrombosis among the 17,263 patients who underwent PCI (1.6% vs. 2.3%; hazard ratio, 0.68; 95% CI, 0.55 to 0.85; P=0.001). There was no significant difference between higher-dose and lower-dose aspirin with respect to the primary outcome (4.2% vs. 4.4%; hazard ratio, 0.97; 95% CI, 0.86 to 1.09; P=0.61) or major bleeding (2.3% vs. 2.3%; hazard ratio, 0.99; 95% CI, 0.84 to 1.17; P=0.90). In patients with an acute coronary syndrome who were referred for an invasive strategy, there was no significant difference between a 7-day, double-dose clopidogrel regimen and the standard-dose regimen, or between higher-dose aspirin and lower-dose aspirin, with respect to the primary outcome of cardiovascular death, myocardial infarction, or

Coronary revascularization in patients with liver cirrhosis.

PubMed

Marui, Akira; Kimura, Takeshi; Tanaka, Shiro; Miwa, Senri; Yamazaki, Kazuhiro; Minakata, Kenji; Nakata, Tomohiro; Ikeda, Tadashi; Furukawa, Yutaka; Kita, Toru; Sakata, Ryuzo

2011-05-01

Liver cirrhosis is a major risk factor for cardiac surgery using cardiopulmonary bypass. However, percutaneous coronary intervention (PCI) or off-pump coronary artery bypass graft surgery (OPCABG) may be a less invasive alternative strategy. Among the 9,877 patients undergoing first PCI or CABG enrolled in the CREDO-Kyoto Registry (a registry of first-time PCI and CABG patients in Japan), 332 patients diagnosed with liver cirrhosis were entered into the study (age 67.1±9.4 years; 246 male). Liver cirrhosis was diagnosed by liver biopsy or signs of portal hypertension with characteristic morphologic liver and spleen changes. A total of 233 patients received PCI, 58 conventional on-pump CABG (CCABG), and 41 OPCABG. Median follow-up was 3.3 years. The PCI group included less complex coronary lesions such as triple vessel and left main disease (p<0.01 each). Propensity score adjusted in-hospital mortality after CCABG or OPCABG was higher than that after PCI; however, the differences were not significant (odds ratio [95% confidence interval]: 6.84 [0.52 to 90.8], p=0.14 for CCABG versus PCI; and 1.86 [0.08 to 45.8], p=0.71 for OPCABG versus PCI). Adjusted overall mortality after CCABG or CABG was lower than that after PCI, but the differences were not significant (0.66 [0.31 to 1.40], p=0.28; and 0.64 [0.28 to 1.49], p=0.31, respectively). Approximately two thirds of patients died of noncardiovascular morbidities (malignancies, including hepatocarcinoma, or hepatic decompression). Because overall noncardiovascular mortality is high among patients with liver cirrhosis, complete revascularization may not be associated with better survival outcomes. Further study is warranted to determine the impact of a coronary revascularization strategy for liver cirrhosis patients. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Cardiac magnetic resonance imaging for the diagnosis of coronary artery disease: an evidence-based analysis.

PubMed

2010-01-01

In July 2009, the Medical Advisory Secretariat (MAS) began work on Non-Invasive Cardiac Imaging Technologies for the Diagnosis of Coronary Artery Disease (CAD), an evidence-based review of the literature surrounding different cardiac imaging modalities to ensure that appropriate technologies are accessed by patients suspected of having CAD. This project came about when the Health Services Branch at the Ministry of Health and Long-Term Care asked MAS to provide an evidentiary platform on effectiveness and cost-effectiveness of non-invasive cardiac imaging modalities.After an initial review of the strategy and consultation with experts, MAS identified five key non-invasive cardiac imaging technologies for the diagnosis of CAD. Evidence-based analyses have been prepared for each of these five imaging modalities: cardiac magnetic resonance imaging, single photon emission computed tomography, 64-slice computed tomographic angiography, stress echocardiography, and stress echocardiography with contrast. For each technology, an economic analysis was also completed (where appropriate). A summary decision analytic model was then developed to encapsulate the data from each of these reports (available on the OHTAC and MAS website).The Non-Invasive Cardiac Imaging Technologies for the Diagnosis of Coronary Artery Disease series is made up of the following reports, which can be publicly accessed at the MAS website at: www.health.gov.on.ca/mas or at www.health.gov.on.ca/english/providers/program/mas/mas_about.htmlSINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY FOR THE DIAGNOSIS OF CORONARY ARTERY DISEASE: An Evidence-Based AnalysisSTRESS ECHOCARDIOGRAPHY FOR THE DIAGNOSIS OF CORONARY ARTERY DISEASE: An Evidence-Based AnalysisSTRESS ECHOCARDIOGRAPHY WITH CONTRAST FOR THE DIAGNOSIS OF CORONARY ARTERY DISEASE: An Evidence-Based Analysis64-Slice Computed Tomographic Angiography for the Diagnosis of Coronary Artery Disease: An Evidence-Based AnalysisCARDIAC MAGNETIC RESONANCE IMAGING FOR

Coronary CT angiography using 64 detector rows: methods and design of the multi-centre trial CORE-64.

PubMed

Miller, Julie M; Dewey, Marc; Vavere, Andrea L; Rochitte, Carlos E; Niinuma, Hiroyuki; Arbab-Zadeh, Armin; Paul, Narinder; Hoe, John; de Roos, Albert; Yoshioka, Kunihiro; Lemos, Pedro A; Bush, David E; Lardo, Albert C; Texter, John; Brinker, Jeffery; Cox, Christopher; Clouse, Melvin E; Lima, João A C

2009-04-01

Multislice computed tomography (MSCT) for the noninvasive detection of coronary artery stenoses is a promising candidate for widespread clinical application because of its non-invasive nature and high sensitivity and negative predictive value as found in several previous studies using 16 to 64 simultaneous detector rows. A multi-centre study of CT coronary angiography using 16 simultaneous detector rows has shown that 16-slice CT is limited by a high number of nondiagnostic cases and a high false-positive rate. A recent meta-analysis indicated a significant interaction between the size of the study sample and the diagnostic odds ratios suggestive of small study bias, highlighting the importance of evaluating MSCT using 64 simultaneous detector rows in a multi-centre approach with a larger sample size. In this manuscript we detail the objectives and methods of the prospective "CORE-64" trial ("Coronary Evaluation Using Multidetector Spiral Computed Tomography Angiography using 64 Detectors"). This multi-centre trial was unique in that it assessed the diagnostic performance of 64-slice CT coronary angiography in nine centres worldwide in comparison to conventional coronary angiography. In conclusion, the multi-centre, multi-institutional and multi-continental trial CORE-64 has great potential to ultimately assess the per-patient diagnostic performance of coronary CT angiography using 64 simultaneous detector rows.

Connecting the coronaries: How the coronary plexus develops and is functionalized

PubMed Central

Dyer, Laura; Pi, Xinchun; Patterson, Cam

2015-01-01

The establishment of the coronary circulation is one of the final critical steps during heart development. Despite decades of research, our understanding of how the coronary vasculature develops and connects to the aorta remains limited. This review serves two specific purposes: it addresses recent advances in understanding the origin of the coronary endothelium, and it then focuses on the last crucial step of coronary vasculature development, the connection of the coronary plexus to the aorta. The chick and quail animal models have yielded most of the information for how these connections form, starting with a fine network of vessels that penetrate the aorta and coalesce to form two distinct ostia. Studies in mouse and rat confirm that at least some of these steps are conserved in mammals, but gaps still exist in our understanding of mammalian coronary ostia formation. The signaling cues necessary to guide the coronary plexus to the aorta are also incompletely understood. Hypoxia-inducible transcription factor-1 and its downstream targets are among the few identified genes that promote the formation of the coronary stems. Together, this review summarizes our current knowledge of coronary vascular formation and highlights the significant gaps that remain. In addition, it highlights some of the coronary artery anomalies known to affect human health, demonstrating that even seemingly subtle defects arising from incorrect coronary plexus formation can result in significant health crises. PMID:25173872

Outcomes with invasive vs conservative management of cardiogenic shock complicating acute myocardial infarction.

PubMed

Bangalore, Sripal; Gupta, Navdeep; Guo, Yu; Lala, Anuradha; Balsam, Leora; Roswell, Robert O; Reyentovich, Alex; Hochman, Judith S

2015-06-01

In the SHOCK trial, an invasive strategy of early revascularization was associated with a significant mortality benefit at 6 months when compared with initial stabilization in patients with cardiogenic shock complicating acute myocardial infarction. Our objectives were to evaluate the data on real-world practice and outcomes of invasive vs conservative management in patients with cardiogenic shock. We analyzed data from the Nationwide Inpatient Sample from 2002 to 2011 with primary discharge diagnosis of acute myocardial infarction and secondary diagnosis of cardiogenic shock. Propensity score matching was used to assemble a cohort of patients managed invasively (with cardiac catheterization, percutaneous coronary intervention, or coronary artery bypass graft surgery) vs conservatively with similar baseline characteristics. The primary outcome was in-hospital mortality. We identified 60,833 patients with cardiogenic shock, of which 20,644 patients (10,322 in each group) with similar propensity scores, including 11,004 elderly patients (≥75 years), were in the final analysis. Patients who underwent invasive management had 59% lower odds of in-hospital mortality (37.7% vs 59.7%; odds ratio [OR] 0.41; 95% confidence interval [CI], 0.39-0.43; P < .0001) when compared with those managed conservatively. This lower mortality was consistently seen across all tested subgroups; specifically in the elderly (≥75 years) (44.0% vs 63.6%; OR 0.45; 95% CI, 0.42-0.49; P < .0001) and those younger than 75 years (30.6% vs 55.1%; OR 0.36; 95% CI, 0.33-0.39; P < .0001), although the magnitude of risk reduction differed (Pinteraction < .0001). In this largest cohort of patients with cardiogenic shock complicating acute myocardial infarction, patients managed invasively had significantly lower mortality when compared with those managed conservatively, even in the elderly. Our results emphasize the need for aggressive management in this high-risk subgroup. Copyright © 2015 Elsevier

Anomalous origin of right coronary artery from left coronary sinus.

PubMed

Hamzeh, Gadah; Crespo, Alex; Estarán, Rafael; Rodríguez, Miguel A; Voces, Roberto; Aramendi, José I

2008-08-01

Anomalous aortic origin of the coronary arteries is uncommon but clinically significant. Manifestations vary from asymptomatic patients to those who present with angina pectoris, myocardial infarction, heart failure, syncope, arrhythmias, and sudden death. We describe 4 patients, aged 34 to 59 years, who were diagnosed with right coronary artery arising from the left sinus of Valsalva, confirmed by coronary angiography, which was surgically repaired. Three patients presented dyspnea and angina, and one with acute myocardial infarction. At operation, the right coronary artery was dissected at the take-off from the intramural course, and reimplanted into the right sinus of Valsalva. There was no mortality. One patient had associated coronary artery disease that required stent placement postoperatively. This reimplantation technique provides a good physiological and anatomical repair, eliminates a slit-like ostium, avoids compression of the coronary artery between the aorta and the pulmonary artery, and gives superior results to coronary artery bypass grafting or the unroofing technique.

Uncertainty Quantification in Multi-Scale Coronary Simulations Using Multi-resolution Expansion

NASA Astrophysics Data System (ADS)

Tran, Justin; Schiavazzi, Daniele; Ramachandra, Abhay; Kahn, Andrew; Marsden, Alison

2016-11-01

Computational simulations of coronary flow can provide non-invasive information on hemodynamics that can aid in surgical planning and research on disease propagation. In this study, patient-specific geometries of the aorta and coronary arteries are constructed from CT imaging data and finite element flow simulations are carried out using the open source software SimVascular. Lumped parameter networks (LPN), consisting of circuit representations of vascular hemodynamics and coronary physiology, are used as coupled boundary conditions for the solver. The outputs of these simulations depend on a set of clinically-derived input parameters that define the geometry and boundary conditions, however their values are subjected to uncertainty. We quantify the effects of uncertainty from two sources: uncertainty in the material properties of the vessel wall and uncertainty in the lumped parameter models whose values are estimated by assimilating patient-specific clinical and literature data. We use a generalized multi-resolution chaos approach to propagate the uncertainty. The advantages of this approach lies in its ability to support inputs sampled from arbitrary distributions and its built-in adaptivity that efficiently approximates stochastic responses characterized by steep gradients.

Non-invasive assessment of low- and intermediate-risk patients with chest pain

PubMed Central

Balfour, Pelbreton C.; Gonzalez, Jorge A.; Kramer, Christopher M.

2016-01-01

Coronary artery disease (CAD) remains a significant global public health burden despite advancements in prevention and therapeutic strategies. Common non-invasive imaging modalities, anatomic and functional, are available for the assessment of patients with stable chest pain. Exercise electrocardiography is a long-standing method for evaluation for CAD and remains the initial test for the majority of patients who can exercise adequately with a baseline interpretable electrocardiogram. The addition of cardiac imaging to exercise testing provides incremental benefit for accurate diagnosis for CAD and is particularly useful in patients who are unable to exercise adequately and/or have uninterpretable electrocardiograms. Radionuclide myocardial perfusion imaging and echocardiography with exercise or pharmacological stress provide high sensitivity and specificity in the detection and further risk stratification of patients with CAD. Recently, coronary computed tomography angiography has demonstrated its growing role to rule out significant CAD given its high negative predictive value. Although less available, stress cardiac magnetic resonance provides a comprehensive assessment of cardiac structure and function and provides a high diagnostic accuracy in the detection of CAD. The utilization of non-invasive testing is complex due to various advantages and limitations, particularly in the assessment of low- and intermediate-risk patients with chest pain, where no single study is suitable for all patients. This review will describe currently available non-invasive modalities, along with current evidence-based guidelines and appropriate use criteria in the assessment of low- and intermediate-risk patients with suspected, stable CAD. PMID:27717538

Topical, geospatial, and temporal diffusion of the 2015 North American Menopause Society position statement on nonhormonal management of vasomotor symptoms.

PubMed

Carpenter, Janet S; Laine, Tei; Harrison, Blake; LePage, Meghan; Pierce, Taran; Hoteling, Nathan; Börner, Katy

2017-10-01

We sought to depict the topical, geospatial, and temporal diffusion of the 2015 North American Menopause Society position statement on the nonhormonal management of menopause-associated vasomotor symptoms released on September 21, 2015, and its associated press release from September 23, 2015. Three data sources were used: online news articles, National Public Radio, and Twitter. For topical diffusion, we compared keywords and their frequencies among the position statement, press release, and online news articles. We also created a network figure depicting relationships across key content categories or nodes. For geospatial diffusion within the United States, we compared locations of the 109 National Public Radio (NPR) stations covering the statement to 775 NPR stations not covering the statement. For temporal diffusion, we normalized and segmented Twitter data into periods before and after the press release (September 12, 2015 to September 22, 2015 vs September 23, 2015 to October 3, 2015) and conducted a burst analysis to identify changes in tweets from before to after. Topical information diffused across sources was similar with the exception of the more scientific terms "vasomotor symptoms" or "vms" versus the more colloquial term "hot flashes." Online news articles indicated media coverage of the statement was mainly concentrated in the United States. NPR station data showed similar proportions of stations airing the story across the four census regions (Northeast, Midwest, south, west; P = 0.649). Release of the statement coincided with bursts in the menopause conversation on Twitter. The findings of this study may be useful for directing the development and dissemination of future North American Menopause Society position statements and/or press releases.

New congenital coronary artery anomaly - double supply of single left anterior descending coronary artery from the left and right coronary sinuses: a case report.

PubMed

Daralammouri, Yunis; Ghannam, Malik; Lauer, Bernward

2016-08-02

A normal anatomy of coronary arteries is important to have adequate cardiac muscle blood supply especially during extraneous physical activities. This case report describes a rare coronary anomaly in which the accessory coronary artery arose from the right coronary artery, reentered the left anterior descending coronary artery, and then ran as a single vessel. We present a case of a coronary anomaly in a 47-year-old white man who presented with atypical angina. Computed tomographic angiography and coronary angiography showed a variant of dual left anterior descending coronary artery not previously described. Our patient's accessory coronary artery arose from his right coronary artery. It took an intramuscular course beneath the right ventricular outflow tract in the interventricular septal area to the anterior interventricular sulcus, giving off septal perforators that reentered his medial left anterior descending coronary artery. Both vessels ran after the anastomosis in the anterior interventricular sulcus as a single vessel. We propose that this anomaly represents a new variant of coronary artery anomaly. This coronary artery anomaly does not cause ischemia. Recognition of this coronary anomaly is important in patients undergoing percutaneous coronary intervention or coronary artery bypass graft operations.

Highly sensitive troponin and coronary computed tomography angiography in the evaluation of suspected acute coronary syndrome in the emergency department.

PubMed

Ferencik, Maros; Hoffmann, Udo; Bamberg, Fabian; Januzzi, James L

2016-08-07

The evaluation of patients presenting to the emergency department with suspected acute coronary syndrome (ACS) remains a clinical challenge. The traditional assessment includes clinical risk assessment based on cardiovascular risk factors with serial electrocardiograms and cardiac troponin measurements, often followed by advanced cardiac testing as inpatient or outpatient (i.e. stress testing, imaging). Despite this costly and lengthy work-up, there is a non-negligible rate of missed ACS with an increased risk of death. There is a clinical need for diagnostic strategies that will lead to rapid and reliable triage of patients with suspected ACS. We provide an overview of the evidence for the role of highly sensitive troponin (hsTn) in the rapid and efficient evaluation of suspected ACS. Results of recent research studies have led to the introduction of hsTn with rapid rule-in and rule-out protocols into the guidelines. Highly sensitive troponin increases the sensitivity for the detection of myocardial infarction and decreases time to diagnosis; however, it may decrease the specificity, especially when used as a dichotomous variable, rather than continuous variable as recommended by guidelines; this may increase clinician uncertainty. We summarize the evidence for the use of coronary computed tomography angiography (CTA) as the rapid diagnostic tool in this population when used with conventional troponin assays. Coronary CTA significantly decreases time to diagnosis and discharge in patients with suspected ACS, while being safe. However, it may lead to increase in invasive procedures and includes radiation exposure. Finally, we outline the opportunities for the combined use of hsTn and coronary CTA that may result in increased efficiency, decreased need for imaging, lower cost, and decreased radiation dose. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.

Arterial Switch Operation With and Without Coronary Relocation for Intramural Coronary Arteries.

PubMed

Koshiyama, Hiroshi; Nagashima, Mitsugi; Matsumura, Goki; Hiramatsu, Takeshi; Nakanishi, Toshio; Yamazaki, Kenji

2016-10-01

The arterial switch operation (ASO) for the transposition of the great arteries (TGA) with intramural coronary arteries has been performed using several techniques to avoid coronary events. We mainly performed ASO without coronary relocation by creating an aortopulmonary fenestration (Imai technique). Coronary circulation was rerouted by covering the aortopulmonary window and coronary orifices with a nonfacing sinus flap. Long-term results have not been reported. We describe our early and late results. Among 551 patients who underwent an ASO between 1985 and 2014, intramural coronary arteries were detected in 15 of them. Coronary arteries were managed using 2 techniques: the double-button method in 5 patients (with unroofing and trapdoor incision in 1 patient) and the Imai technique in 10 patients. There were 3 hospital deaths and 3 deaths after discharge, 5 of which showed coronary complications. Actual survival and freedom from coronary complications at 15 years were 70% and 67%, respectively, with the Imai technique and 40% and 20%, respectively, with the double-button method. Late coronary intervention was performed for a long intramural coronary artery stenosis in 1 patient who underwent the Imai technique. In the others, late aortography showed good patency of the aortopulmonary window and growth of the coronary pouch after the Imai technique. The Imai technique can be an option for coronary management in the presence of high-risk coronary anatomy, particularly distal intramural coronary artery stenosis and inseparable coronary arteries with an almost single orifice. Adequate neopulmonary artery augmentation must be performed to prevent right ventricular outflow stenosis. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Economic evaluation of bivalirudin with or without glycoprotein IIb/IIIa inhibition versus heparin with routine glycoprotein IIb/IIIa inhibition for early invasive management of acute coronary syndromes.

PubMed

Pinto, Duane S; Stone, Gregg W; Shi, Chunxue; Dunn, Elizabeth S; Reynolds, Matthew R; York, Meghan; Walczak, Joshua; Berezin, Ronna H; Mehran, Roxana; McLaurin, Brent T; Cox, David A; Ohman, E Magnus; Lincoff, A Michael; Cohen, David J

2008-11-25

The aim of this study was to determine the economic impact of several anticoagulation strategies for moderate- and high-risk non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients managed invasively. The ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial demonstrated that bivalirudin monotherapy yields similar rates of ischemic complications and less bleeding than regimens incorporating glycoprotein IIb/IIIa receptor inhibitors (GPI) for moderate- and high-risk NSTE-ACS. In ACUITY, 7,851 U.S. patients were randomized to: 1) heparin (unfractionated or enoxaparin) + GPI; 2) bivalirudin + GPI; or 3) bivalirudin monotherapy. Patients assigned to GPI were also randomized to upstream GPI before catheterization or selective GPI only with percutaneous coronary intervention. Resource use data were collected prospectively through 30-day follow-up. Costs were estimated with standard methods including resource-based accounting, hospital billing data, and the Medicare fee schedule. At 30 days, ischemic events were similar for all groups. Major bleeding was reduced with bivalirudin monotherapy compared with heparin + GPI or bivalirudin + GPI (p < 0.001). Length of stay was lowest with bivalirudin monotherapy or bivalirudin + catheterization laboratory GPI (p = 0.02). Despite higher drug costs, aggregate hospital stay costs were lowest with bivalirudin monotherapy (mean difference range: $184 to $1,081, p < 0.001 for overall comparison) and at 30 days (mean difference range: $123 to $938, p = 0.005). Regression modeling demonstrated that hospital savings were primarily due to less major and minor bleeding with bivalirudin ($8,658/event and $2,282/event, respectively). Among U.S. patients in the ACUITY trial, bivalirudin monotherapy compared with heparin + GPI resulted in similar protection from ischemic events, reduced bleeding, and shorter length of stay. Despite higher drug costs, aggregate hospital and 30-day costs were lowest with

Non-invasive detection of aortic and coronary atherosclerosis in homozygous familial hypercholesterolemia by 64 slice multi-detector row computed tomography angiography

USDA-ARS?s Scientific Manuscript database

Homozygous familial hypercholesterolemia (HoFH) is a rare disorder characterized by the early onset of atherosclerosis, often at the ostia of coronary arteries. In this study we document for the first time that aortic and coronary atherosclerosis can be detected using 64 slice multiple detector row ...

Diagnostic accuracy of high-definition CT coronary angiography in high-risk patients.

PubMed

Iyengar, S S; Morgan-Hughes, G; Ukoumunne, O; Clayton, B; Davies, E J; Nikolaou, V; Hyde, C J; Shore, A C; Roobottom, C A

2016-02-01

To assess the diagnostic accuracy of computed tomography coronary angiography (CTCA) using a combination of high-definition CT (HD-CTCA) and high level of reader experience, with invasive coronary angiography (ICA) as the reference standard, in high-risk patients for the investigation of coronary artery disease (CAD). Three hundred high-risk patients underwent HD-CTCA and ICA. Independent experts evaluated the images for the presence of significant CAD, defined primarily as the presence of moderate (≥ 50%) stenosis and secondarily as the presence of severe (≥ 70%) stenosis in at least one coronary segment, in a blinded fashion. HD-CTCA was compared to ICA as the reference standard. No patients were excluded. Two hundred and six patients (69%) had moderate and 178 (59%) had severe stenosis in at least one vessel at ICA. The sensitivity, specificity, positive predictive value, and negative predictive value were 97.1%, 97.9%, 99% and 93.9% for moderate stenosis, and 98.9%, 93.4%, 95.7% and 98.3%, for severe stenosis, on a per-patient basis. The combination of HD-CTCA and experienced readers applied to a high-risk population, results in high diagnostic accuracy comparable to ICA. Modern generation CT systems in experienced hands might be considered for an expanded role. Copyright © 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Prospective Clinical Trial of Robotically Assisted Endoscopic Coronary Grafting With 1-Year Follow-Up

PubMed Central

Prasad, Sunil M.; Ducko, Christopher T.; Stephenson, Edward R.; Chambers, Charles E.; Damiano, Ralph J.

2001-01-01

Objective To follow up in prospective fashion patients with coronary artery anastomoses completed endoscopically with robotic assistance. The robotic system was evaluated for safety and its effectiveness in completing microsurgical coronary anastomoses. Summary Background Data Recently there has been an interest in using robotics and computers to enhance the surgeon’s ability to perform endoscopic cardiac surgery. This interest has stemmed from the rapid advancement of technology and the desire to make cardiac surgery less invasive. Using traditional endoscopic instruments, it has not been possible to perform coronary surgery. Methods Nineteen patients underwent robotically assisted endoscopic coronary artery bypass grafting of the left internal thoracic artery (LITA) to the left anterior descending artery (LAD). Two robotic instruments and one endoscopic camera were placed through three 5-mm ports. A robotic system was used to construct the LITA–LAD anastomosis. All other required grafts were completed by conventional techniques. Results Seventeen LITA–LAD grafts (89%) had adequate intraoperative flow. The mean LITA–LAD graft flow was 38.5 ± 5 mL/min. At 8 weeks, LITA–LAD grafts were assessed by angiography and showed 100% patency with thrombolysis in myocardial infarction (TIMI) I flow. At a mean follow-up of 17 ± 4.2 months, all patients were NYHA class I and there were no adverse cardiac events. Conclusions The results from the first prospective clinical trial of robotically assisted endoscopic coronary bypass surgery in the United States showed favorable short-term outcomes with no adverse events. Robotic assistance is an enabling technology allowing the performance of endoscopic coronary anastomoses. PMID:11371730

Clinical outcome, pain perception and activities of daily life after minimally invasive coronary artery bypass grafting.

PubMed

Uymaz, Barış; Sezer, Gül; Köksal Coşkun, Pınar; Tarcan, Onurcan; Ozleme, Seyhan; Aybek, Tayfun

2014-03-01

Minimally invasive direct coronary artery bypass (MIDCAB) for revascularization of the left anterior descending artery has become a routine operation. We present our clinical experiences with beating heart MIDCAB surgery performed through partial lower sternotomy (PLS) and retrospectively compare the results of pain perception as well as activities of daily life (ADL) with the conventional full sternotomy. From January 2009 to August 2012, 197 patients underwent MIDCAB using modified PLS at our hospital. Their mean age was 58.5±10.5 years. 54 (28%) had previous myocardial infarction, 38 (19%) had diabetes mellitus. The visual analog scale (VAS) for pain one, two and three, the ADL score for mobilization were obtained within four days after surgery. 98% of patients were followed-up with both direct visits and questionnaires to assess the major adverse cardiac events (MACE). We performed t-test for comperative data and Kaplan-Meier curves for survival analysis. There was one postoperative death (0.5%) and three conversions to full sternotomy (1.5%). Postoperative angiography was performed in 34 (17.2%) patients, who had some symptoms during the follow-up period of 45 months. The graft patency rate was 96.5% (190 of 197). At follow-up (24.1±11.7 months), survival free of MACE was 91.8±3.1% at 3.5 years. Both the Visual Analog Scale (35.1±9.6 vs. 57.1±7.8) and the ADL score (80.4±11.8 vs. 36.2±8.6) were significantly higher after the operation in comparison to the matched group of beating heart revascularizations with full sternotomy (p<0.001). This study demonstrates that the MIDCAB using PLS can achieve an effective intermediate-term revascularization and an acceptable clinical outcome. Patients who undergo this procedure are free of major complications and enjoy good quality of life after surgery.

Coronary artery disease

MedlinePlus Videos and Cool Tools

The coronary arteries supply blood to the heart muscle itself. Damage to or blockage of a coronary artery can result in injury to the heart. Normally, blood flows through a coronary artery unimpeded. However, a ...

Targeting clinical outcomes: Endovascular simulation improves diagnostic coronary angiography skills.

PubMed

Schimmel, Daniel R; Sweis, Ranya; Cohen, Elaine R; Davidson, Charles; Wayne, Diane B

2016-02-15

The purpose of this study is to determine the effects of simulation-based medical education (SBME) on the skills required to perform coronary angiography in the cardiac catheterization laboratory. Cardiovascular fellows commonly learn invasive procedures on patients. Because this approach is not standardized, it can result in inconsistent skill acquisition through exclusion of concepts and skills. Also, the learning curve varies between trainees yielding variability in skill acquisition. Therefore, coronary angiography skills are an excellent target for SBME in an environment in which direct patient care is not jeopardized. From January 2013 to June 2013, 14 cardiovascular fellows entering the cardiac catheterization laboratory at a tertiary care teaching hospital were tested on an endovascular simulator to assess baseline skills. All fellows subsequently underwent didactic teaching and preceptor-lead training on the endovascular simulator. Topics included basic catheterization skills and a review of catheterization laboratory systems. Following training, all fellows underwent a post-training assessment on the endovascular simulator. Paired t tests were used to compare items on the skills checklist and simulator defined variables. Cardiovascular fellows scored significantly higher on a diagnostic coronary angiography skills checklist following SBME using an endovascular simulator. The mean pretest score was 66.6% (SD = 9.7%) compared to 86.0% (SD = 6.3%) following simulator training (P < 0.001). Additional findings include significant reduction in procedure time and use of cine-fluoroscopy at posttest. SBME significantly improved cardiovascular fellows' performance of simulated coronary angiography skills. Standardized simulation-based education is a valuable adjunct to traditional clinical education for cardiovascular fellows. © 2015 Wiley Periodicals, Inc.

Predicting coronary artery disease using different artificial neural network models.

PubMed

Colak, M Cengiz; Colak, Cemil; Kocatürk, Hasan; Sağiroğlu, Seref; Barutçu, Irfan

2008-08-01

Eight different learning algorithms used for creating artificial neural network (ANN) models and the different ANN models in the prediction of coronary artery disease (CAD) are introduced. This work was carried out as a retrospective case-control study. Overall, 124 consecutive patients who had been diagnosed with CAD by coronary angiography (at least 1 coronary stenosis > 50% in major epicardial arteries) were enrolled in the work. Angiographically, the 113 people (group 2) with normal coronary arteries were taken as control subjects. Multi-layered perceptrons ANN architecture were applied. The ANN models trained with different learning algorithms were performed in 237 records, divided into training (n=171) and testing (n=66) data sets. The performance of prediction was evaluated by sensitivity, specificity and accuracy values based on standard definitions. The results have demonstrated that ANN models trained with eight different learning algorithms are promising because of high (greater than 71%) sensitivity, specificity and accuracy values in the prediction of CAD. Accuracy, sensitivity and specificity values varied between 83.63%-100%, 86.46%-100% and 74.67%-100% for training, respectively. For testing, the values were more than 71% for sensitivity, 76% for specificity and 81% for accuracy. It may be proposed that the use of different learning algorithms other than backpropagation and larger sample sizes can improve the performance of prediction. The proposed ANN models trained with these learning algorithms could be used a promising approach for predicting CAD without the need for invasive diagnostic methods and could help in the prognostic clinical decision.

The identification of the variation of atherosclerosis plaques by invasive and non-invasive methods

NASA Technical Reports Server (NTRS)

Selzer, R. H.; Blankenhorn, D. H.

1982-01-01

Computer-enhanced visualization of coronary arteries and lesions within them is discussed, comparing invasive and noninvasive methods. Trial design factors in computer lesions assessment are briefly discussed, and the use of the computer edge-tracking technique in that assessment is described. The results of a small pilot study conducted on serial cineangiograms of men with premature atherosclerosis are presented. A canine study to determine the feasibility of quantifying atherosclerosis from intravenous carotid angiograms is discussed. Comparative error for arterial and venous injection in the canines is determined, and the mode of processing the films to achieve better visualization is described. The application of the computer edge-tracking technique to an ultrasound image of the human carotid artery is also shown and briefly discussed.

Coronary Artery Anomalies in Animals

PubMed Central

Scansen, Brian A.

2017-01-01

Coronary artery anomalies represent a disease spectrum from incidental to life-threatening. Anomalies of coronary artery origin and course are well-recognized in human medicine, but have received limited attention in veterinary medicine. Coronary artery anomalies are best described in the dog, hamster, and cow though reports also exist in the horse and pig. The most well-known anomaly in veterinary medicine is anomalous coronary artery origin with a prepulmonary course in dogs, which limits treatment of pulmonary valve stenosis. A categorization scheme for coronary artery anomalies in animals is suggested, dividing these anomalies into those of major or minor clinical significance. A review of coronary artery development, anatomy, and reported anomalies in domesticated species is provided and four novel canine examples of anomalous coronary artery origin are described: an English bulldog with single left coronary ostium and a retroaortic right coronary artery; an English bulldog with single right coronary ostium and transseptal left coronary artery; an English bulldog with single right coronary ostium and absent left coronary artery with a prepulmonary paraconal interventricular branch and an interarterial circumflex branch; and a mixed-breed dog with tetralogy of Fallot and anomalous origin of all coronary branches from the brachiocephalic trunk. Coronary arterial fistulae are also described including a coronary cameral fistula in a llama cria and an English bulldog with coronary artery aneurysm and anomalous shunting vessels from the right coronary artery to the pulmonary trunk. These examples are provided with the intent to raise awareness and improve understanding of such defects. PMID:29056679

Coronary atherosclerosis evaluation among Iranian patients with zero coronary calcium score in computed tomography coronary angiography.

PubMed

Moradi, Maryam; Varasteh, Elham

2016-01-01

Coronary artery calcification (CAC) is a specific indicator of and a sensitive marker for the atherosclerotic disease process. However, calcium scoring may miss noncalcified plaques with clinical importance. The present study aimed to identify the presence and extent of coronary plaques in computed tomography coronary angiography (CTCA) in patients with a zero CAC score and the secondary endpoint was to evaluate the association between coronary risk factors and the presence of noncalcified plaques. In a retrospective descriptive-analytic study, a total of 2000 consecutive patients who undergone CTCA between September 2012 and September 2014 at Alzahra Hospital in Isfahan, Iran were analyzed. Three hundred and eighty-five patients with a zero calcium score were included in the study. The demographic information and coronary artery disease (CAD), risk factors including diabetes mellitus (DM), hypertension, hyperlipidemia, smoking, and family history of CAD, were obtained from the questionnaire. Furthermore, the presence of plaques and extent of stenosis were evaluated in patients with zero CAC score. Of the 385 patients with a zero calcium score, 16 (4.2%) had atherosclerotic plaques. Among them, 6 (1.6%) had significant (>50%) coronary stenosis, and 10 (2.6%) had no significant (<50%) coronary stenosis. Hyperlipidemia, DM, and smoking were significantly associated with obstructive CAD. Furthermore, in patients with zero calcium score, DM, hyperlipidemia, and smoking had odds ratios of 5.9, 14, and 32.5 for the development of coronary artery plaques, respectively. Although, CAC scoring is a noninvasive and valuable method to evaluate CAD; but zero CAC score does not absolutely exclude the CAD, especially in the presence of risk factors such as diabetes, hyperlipidemia, and smoking.

Biomarkers of coronary endothelial health: correlation with invasive measures of collateral function, flow and resistance in chronically occluded coronary arteries and the effect of recanalization.

PubMed

Ladwiniec, Andrew; Ettelaie, Camille; Cunnington, Michael S; Rossington, Jennifer; Thackray, Simon; Alamgir, Farquad; Hoye, Angela

2016-06-01

In the presence of a chronically occluded coronary artery, the collateral circulation matures by a process of arteriogenesis; however, there is considerable variation between individuals in the functional capacity of that collateral network. This could be explained by differences in endothelial health and function. We aimed to examine the relationship between the functional extent of collateralization and levels of biomarkers that have been shown to relate to endothelial health. We measured four potential biomarkers of endothelial health in 34 patients with mature collateral networks who underwent a successful percutaneous coronary intervention (PCI) for a chronic total coronary occlusion (CTO) before PCI and 6-8 weeks after PCI, and examined the relationship of biomarker levels with physiological measures of collateralization. We did not find a significant change in the systemic levels of sICAM-1, sE-selectin, microparticles or tissue factor 6-8 weeks after PCI. We did find an association between estimated retrograde collateral flow before CTO recanalization and lower levels of sICAM-1 (r=0.39, P=0.026), sE-selectin (r=0.48, P=0.005) and microparticles (r=0.38, P=0.03). Recanalization of a CTO and resultant regression of a mature collateral circulation do not alter systemic levels of sICAM-1, sE-selectin, microparticles or tissue factor. The identified relationship of retrograde collateral flow with sICAM-1, sE-selectin and microparticles is likely to represent an association with an ability to develop collaterals rather than their presence and extent.

The performance of non-invasive tests to rule-in and rule-out significant coronary artery stenosis in patients with stable angina: a meta-analysis focused on post-test disease probability.

PubMed

Knuuti, Juhani; Ballo, Haitham; Juarez-Orozco, Luis Eduardo; Saraste, Antti; Kolh, Philippe; Rutjes, Anne Wilhelmina Saskia; Jüni, Peter; Windecker, Stephan; Bax, Jeroen J; Wijns, William

2018-05-29

To determine the ranges of pre-test probability (PTP) of coronary artery disease (CAD) in which stress electrocardiogram (ECG), stress echocardiography, coronary computed tomography angiography (CCTA), single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance (CMR) can reclassify patients into a post-test probability that defines (>85%) or excludes (<15%) anatomically (defined by visual evaluation of invasive coronary angiography [ICA]) and functionally (defined by a fractional flow reserve [FFR] ≤0.8) significant CAD. A broad search in electronic databases until August 2017 was performed. Studies on the aforementioned techniques in >100 patients with stable CAD that utilized either ICA or ICA with FFR measurement as reference, were included. Study-level data was pooled using a hierarchical bivariate random-effects model and likelihood ratios were obtained for each technique. The PTP ranges for each technique to rule-in or rule-out significant CAD were defined. A total of 28 664 patients from 132 studies that used ICA as reference and 4131 from 23 studies using FFR, were analysed. Stress ECG can rule-in and rule-out anatomically significant CAD only when PTP is ≥80% (76-83) and ≤19% (15-25), respectively. Coronary computed tomography angiography is able to rule-in anatomic CAD at a PTP ≥58% (45-70) and rule-out at a PTP ≤80% (65-94). The corresponding PTP values for functionally significant CAD were ≥75% (67-83) and ≤57% (40-72) for CCTA, and ≥71% (59-81) and ≤27 (24-31) for ICA, demonstrating poorer performance of anatomic imaging against FFR. In contrast, functional imaging techniques (PET, stress CMR, and SPECT) are able to rule-in functionally significant CAD when PTP is ≥46-59% and rule-out when PTP is ≤34-57%. The various diagnostic modalities have different optimal performance ranges for the detection of anatomically and functionally significant CAD. Stress ECG appears to

School burnout: increased sympathetic vasomotor tone and attenuated ambulatory diurnal blood pressure variability in young adult women.

PubMed

May, Ross W; Sanchez-Gonzalez, Marcos A; Fincham, Frank D

2015-01-01

Two studies examined autonomic and cardiovascular functioning that may link school burnout to cardiovascular risk factors in young healthy adult females. Study 1 (N = 136) investigated whether school burnout was related to resting values of blood pressure (BP) and blood pressure variability (BPV) through laboratory beat-to-beat BP assessment. Study 2 (N = 94) examined the link between school burnout and diurnal BPV through ambulatory BP monitoring. Controlling for anxiety and depressive symptomatology, school burnout demonstrated strong positive relationships with indices of cardiac sympathovagal tone, sympathetic vasomotor tone, inefficient myocardial oxygen consumption, increased 24-h ambulatory heart rate and BP, blunted BP diurnal variability, and increased arterial stiffness. These studies establish cardiovascular biomarkers of school burnout and suggest that even in a seemingly healthy sample school burnout may predispose females to increased cardiovascular risk. Several future lines of research are outlined.

The clinical evaluation of the CADence device in the acoustic detection of coronary artery disease.

PubMed

Thomas, Joseph L; Ridner, Michael; Cole, Jason H; Chambers, Jeffrey W; Bokhari, Sabahat; Yannopoulos, Demetris; Kern, Morton; Wilson, Robert F; Budoff, Matthew J

2018-06-23

The noninvasive detection of turbulent coronary flow may enable diagnosis of significant coronary artery disease (CAD) using novel sensor and analytic technology. Eligible patients (n = 1013) with chest pain and CAD risk factors undergoing nuclear stress testing were studied using the CADence (AUM Cardiovascular Inc., Northfield MN) acoustic detection (AD) system. The trial was designed to demonstrate non-inferiority of AD for diagnostic accuracy in detecting significant CAD as compared to an objective performance criteria (sensitivity 83% and specificity 80%, with 15% non-inferiority margins) for nuclear stress testing. AD analysis was blinded to clinical, core lab-adjudicated angiographic, and nuclear data. The presence of significant CAD was determined by computed tomographic (CCTA) or invasive angiography. A total of 1013 subjects without prior coronary revascularization or Q-wave myocardial infarction were enrolled. Primary analysis was performed on subjects with complete angiographic and AD data (n = 763) including 111 subjects (15%) with severe CAD based on CCTA (n = 34) and invasive angiography (n = 77). The sensitivity and specificity of AD were 78% (p = 0.012 for non-inferiority) and 35% (p < 0.001 for failure to demonstrate non-inferiority), respectively. AD results had a high 91% negative predictive value for the presence of significant CAD. AD testing failed to demonstrate non-inferior diagnostic accuracy as compared to the historical performance of a nuclear stress OPC due to low specificity. AD sensitivity was non-inferior in detecting significant CAD with a high negative predictive value supporting a potential value in excluding CAD.

Relationship between CHA2DS2-VASc score, coronary artery disease severity, residual platelet reactivity and long-term clinical outcomes in patients with acute coronary syndrome.

PubMed

Scudiero, Fernando; Zocchi, Chiara; De Vito, Elena; Tarantini, Giuseppe; Marcucci, Rossella; Valenti, Renato; Migliorini, Angela; Antoniucci, David; Marchionni, Niccolò; Parodi, Guido

2018-07-01

The CHA 2 DS 2 -VASc score predicts stroke risk in patients with atrial fibrillation, but recently has been reported to have a prognostic role even in patients with ACS. We sought to assess the ability of the CHA 2 DS 2 -VASc score to predict the severity of coronary artery disease, high residual platelet reactivity and long-term outcomes in patients with acute coronary syndrome (ACS). Overall, 1729 consecutive patients with ACS undergoing invasive management were included in this prospective registry. We assessed platelet reactivity via light transmittance aggregometry after clopidogrel loading. Patients were divided according to the CHA 2 DS 2 -VASc score: group A = 0, B = 1, C = 2, D = 3, E = 4 and F ≥ 5. Patients with higher CHA 2 DS 2 -VASc score were more likely to have a higher rate of multivessel CAD (37%, 47%, 55%, 62%, 67 and 75% in Group A, B, C, D, E and F; p < 0.001); moreover, CHA 2 DS 2 -VASc score correlated linearly with residual platelet reactivity (R = 0.77; p < 0.001). At long-term follow-up, estimated adverse event rates (MACCE: cardiac death, MI, stroke or any urgent coronary revascularization) were 3%, 8%, 10%, 14%, 19% and 24% in group A, B, C, D, E and F; p < 0.001. Multivariable analysis demonstrated CHA 2 DS 2 -VASc to be an independent predictor of severity of coronary artery disease, of high residual platelet reactivity and of MACCE. In a cohort of patients with ACS, CHA 2 DS 2 -VASc score correlated with coronary disease severity and residual platelet reactivity, and therefore it predicted the risk of long-term adverse events. Copyright © 2018 Elsevier B.V. All rights reserved.

Assessment Of Coronary Artery Aneurysms Using Transluminal Attenuation Gradient And Computational Modeling In Kawasaki Disease Patients

NASA Astrophysics Data System (ADS)

Grande Gutierrez, Noelia; Kahn, Andrew; Shirinsky, Olga; Gagarina, Nina; Lyskina, Galina; Fukazawa, Ryuji; Owaga, Shunichi; Burns, Jane; Marsden, Alison

2015-11-01

Kawasaki Disease (KD) can result in coronary artery aneurysms (CAA) in up to 25% of patients, putting them at risk of thrombus formation, myocardial infarction and sudden death. Clinical guidelines recommend CAA diameter >8 mm as the arbitrary criterion for initiating systemic anticoagulation. KD patient specific modeling and flow simulations suggest that hemodynamic data can predict regions at increased risk of thrombosis. Transluminal Attenuation Gradient (TAG) is determined from the change in radiological attenuation per vessel length and has been proposed as a non-invasive method for characterizing coronary stenosis from CT Angiography. We hypothesized that CAA abnormal flow could be quantified using TAG. We computed hemodynamics for patient specific coronary models using a stabilized finite element method, coupled numerically to a lumped parameter network to model the heart and vascular boundary conditions. TAG was quantified in the major coronary arteries. We compared TAG for aneurysmal and normal arteries and we analyzed TAG correlation with hemodynamic and geometrical parameters. Our results suggest that TAG may provide hemodynamic data not available from anatomy alone. TAG represents a possible extension to standard CTA that could help to better evaluate the risk of thrombus formation in KD.

Psychophysical and vasomotor evidence for interdependency of TRPA1 and TRPV1 nociceptive responses in human skin: an experimental study.

PubMed

Nielsen, Thomas Arendt; Eriksen, Matilde Alida; Gazerani, Parisa; Andersen, Hjalte Holm

2018-05-25

The TRPA1 and TRPV1 receptors are important pharmaceutical targets for antipruritic and analgesic therapy. Obtaining further knowledge on their roles and inter-relationship in humans is therefore crucial. Preclinical results are contradictory concerning co-expression and functional interdependency of TRPV1 and TRPA1 but no human evidence exists. This human experimental study investigated whether functional responses from the subpopulation of TRPA1-nociceptors could be evoked following defunctionalization of TRPV1-nociceptors by cutaneous application of high-concentration capsaicin. Two quadratic areas on each forearm were randomized to pretreatment with an 8% topical capsaicin patch or vehicle for 24h. Subsequently, areas were provoked by transdermal 1% topical capsaicin (TRPV1 agonist) or 10% topical allyl-isothiocyanate ('AITC', a TRPA1-agonist), delivered by 12mm Finn chambers. Evoked pain intensities were recorded during pretreatments and chemical provocations. Quantitative sensory tests were performed before and after provocations to assess changes of heat pain sensitivity. Imaging of vasomotor responses was used to assess neurogenic inflammation after the chemical provocations. In the capsaicin-pretreated areas both the subsequent 1% capsaicin- and 10% AITC-provoked pain intensities were inhibited by 92.9±2.5% and 86.9±5.0% (both: P<0.001), respectively. The capsaicin-ablated skin areas showed significant heat hypoalgesia at baseline (P<0.001) as well as heat antihyperalgesia, and inhibition of neurogenic inflammation evoked by both 1% capsaicin- and 10% AITC provocations (both: P<0.001). Ablation of capsaicin-sensitive afferents caused consistent and equal inhibition of both TRPV1 and TRPA1-provoked responses assessed psychophysically and by imaging of vasomotor responses. The present study suggests that TRPA1 nociceptive responses in human skin strongly depend on intact capsaicin-sensitive, TPRV1 fibers.

Short-term administration of progesterone and estradiol independently alter carotid-vasomotor, but not carotid-cardiac, baroreflex function in young women.

PubMed

Brunt, Vienna E; Miner, Jennifer A; Kaplan, Paul F; Halliwill, John R; Strycker, Lisa A; Minson, Christopher T

2013-10-01

The individual effects of estrogen and progesterone on baroreflex function remain poorly understood. We sought to determine how estradiol (E2) and progesterone (P4) independently alter the carotid-cardiac and carotid-vasomotor baroreflexes in young women by using a hormone suppression and exogenous add-back design. Thirty-two young women were divided into two groups and studied under three conditions: 1) after 4 days of endogenous hormone suppression with a gonadotropin releasing hormone antagonist (control condition), 2) after continued suppression and 3 to 4 days of supplementation with either 200 mg/day oral progesterone (N = 16) or 0.1 to 0.2 mg/day transdermal 17β-estradiol (N = 16), and 3) after continued suppression and 3 to 4 days of supplementation with both hormones. Changes in heart rate (HR), mean arterial pressure (MAP), and femoral vascular conductance (FVC) were measured in response to 5 s of +50 mmHg external neck pressure to unload the carotid baroreceptors. Significant hormone effects on the change in HR, MAP, and FVC from baseline at the onset of neck pressure were determined using mixed model covariate analyses accounting for P4 and E2 plasma concentrations. Neither P4 (P = 0.95) nor E2 (P = 0.95) affected the HR response to neck pressure. Higher P4 concentrations were associated with an attenuated fall in FVC (P = 0.01), whereas higher E2 concentrations were associated with an augmented fall in FVC (P = 0.02). Higher E2 was also associated with an augmented rise in MAP (P = 0.01). We conclude that progesterone blunts whereas estradiol enhances carotid-vasomotor baroreflex sensitivity, perhaps explaining why no differences in sympathetic baroreflex sensitivity are commonly reported between low and high combined hormone phases of the menstrual cycle.

Short-term administration of progesterone and estradiol independently alter carotid-vasomotor, but not carotid-cardiac, baroreflex function in young women

PubMed Central

Brunt, Vienna E.; Miner, Jennifer A.; Kaplan, Paul F.; Halliwill, John R.; Strycker, Lisa A.

2013-01-01

The individual effects of estrogen and progesterone on baroreflex function remain poorly understood. We sought to determine how estradiol (E2) and progesterone (P4) independently alter the carotid-cardiac and carotid-vasomotor baroreflexes in young women by using a hormone suppression and exogenous add-back design. Thirty-two young women were divided into two groups and studied under three conditions: 1) after 4 days of endogenous hormone suppression with a gonadotropin releasing hormone antagonist (control condition), 2) after continued suppression and 3 to 4 days of supplementation with either 200 mg/day oral progesterone (N = 16) or 0.1 to 0.2 mg/day transdermal 17β-estradiol (N = 16), and 3) after continued suppression and 3 to 4 days of supplementation with both hormones. Changes in heart rate (HR), mean arterial pressure (MAP), and femoral vascular conductance (FVC) were measured in response to 5 s of +50 mmHg external neck pressure to unload the carotid baroreceptors. Significant hormone effects on the change in HR, MAP, and FVC from baseline at the onset of neck pressure were determined using mixed model covariate analyses accounting for P4 and E2 plasma concentrations. Neither P4 (P = 0.95) nor E2 (P = 0.95) affected the HR response to neck pressure. Higher P4 concentrations were associated with an attenuated fall in FVC (P = 0.01), whereas higher E2 concentrations were associated with an augmented fall in FVC (P = 0.02). Higher E2 was also associated with an augmented rise in MAP (P = 0.01). We conclude that progesterone blunts whereas estradiol enhances carotid-vasomotor baroreflex sensitivity, perhaps explaining why no differences in sympathetic baroreflex sensitivity are commonly reported between low and high combined hormone phases of the menstrual cycle. PMID:23873800

Coronary Artery Disease | Coronary Artery Disease | NIH MedlinePlus the Magazine

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... of this page please turn Javascript on. Feature: Coronary Artery Disease Coronary Artery Disease Past Issues / Fall 2010 Table of Contents David ... up inside your arteries. One atherosclerosis-related disease, coronary artery disease (CAD) is the most common heart disease and ...

Early detection of coronary artery disease by 64-slice multidetector computed tomography in asymptomatic hypertensive high-risk patients.

PubMed

Gaudio, Carlo; Mirabelli, Francesca; Pelliccia, Francesco; Francone, Marco; Tanzilli, Gaetano; Di Michele, Sara; Leonetti, Stefania; De Vincentis, Giuseppe; Carbone, Iacopo; Mangieri, Enrico; Catalano, Carlo; Passariello, Roberto

2009-07-10

The 64-slice multidetector-row computed tomography (MDCT) is an accurate noninvasive technique for assessing the degree of luminal narrowing in coronary arteries of patients with chronic ischemic disease. Aim of this study was to determine the value of MDCT in comparison to invasive coronary angiography (ICA) for detecting the presence and extent of coronary atherosclerotic plaques in a population of asymptomatic, hypertensive patients considered to be at high risk for cardiovascular events. We studied 67 asymptomatic, hypertensive patients at high-risk (Euro Score >5%). All patients had negative or nondiagnostic findings at exercise stress testing and therefore underwent both MDCT and ICA. In the per-patient analysis, MDCT correctly identified 16/17 (94%) patients with significant coronary artery disease involving at least 1 vessel and 48/50 (96%) normal subjects. In the per-segment analysis, MDCT correctly detected 21/22 (95%) coronary segments with a stenosis >or=50% and 856/868 (98%) normal segments, with a high negative predictivity of normal scans (100%). There was a good concordance between MDCT and ICA, with a high Pearson correlation coefficient between the coronary narrowings with the two techniques (r=0.84, p<0.01). Mean coronary calcium score was higher for the 17 patients with significant coronary artery disease on ICA than in the 50 patients without (422+/-223 HU vs 72+/-21 HU p<0.001). The ROC curves identified 160 as the best calcium volumetric score cut-off value able to identify >or=1 significant coronary stenosis with sensitivity 88% and specificity 85%. MDCT is an excellent noninvasive technique for early identification of significant coronary stenoses in high risk asymptomatic hypertensive patients and might provide unique information for the screening of this broad population.

Menopausal vasomotor symptoms are associated with poor self-assessed work ability.

PubMed

Gartoulla, Pragya; Bell, Robin J; Worsley, Roisin; Davis, Susan R

2016-05-01

It has been hypothesised that vasomotor symptoms (VMS), the hallmark of menopause, may affect women's workplace performance. The aim of this study was to investigate the association between VMS and self-reported work ability, taking into account socio-demographic characteristics. Study design/Main Outcome measures: A national cross-sectional survey of women, aged 40-65 years, was conducted between October 2013 and March 2014. Participants provided socio-demographic and lifestyle factors and completed the Menopause Specific Quality of Life Questionnaire (MENQOL) and the Work Ability Index (WAI). Of 2020 women who comprised the study sample, 1274 were in paid employment and 1263 completed the WAI. The WAI score was good-excellent for 81.5% of women and poor-moderate for 18.5%. After adjustment for socio-demographic characteristics, having any VMS was associated with greater likelihood of poor-moderate work ability [odds ratio (OR)=2.45, 95% CI 1.69-3.54]. Poorer work ability was significantly and independently associated with being un-partnered, obese or overweight, smoking, being carer and having insecure housing finance, but not with age. Overall, most women functioned well at work. We observed an association suggesting a relationship not only between menopausal VMS and personal wellbeing, but also between VMS and self-assessed work ability. Although 4 in 5 women functioned well at work, recognition of the association with VMS may improve wellbeing and work performance of working women at midlife. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Coronary surgery and coronary angioplasty in patients with two-vessel coronary artery disease.

PubMed

Weintraub, W S; King, S B; Jones, E L; Douglas, J S; Craver, J M; Liberman, H A; Morris, D C; Guyton, R A

1993-03-01

There is uncertainty regarding the selection between coronary artery surgery and angioplasty in many patients with coronary artery disease, especially in those with 2-vessel disease. Whereas randomized trials will provide the best possible and most detailed data comparing therapy in these patients, clinical data bases may be used to provide a current perspective. The purpose of this study was to compare the long-term outcome of patients with 2-vessel coronary artery disease undergoing coronary surgery or angioplasty at Emory University hospitals in the years 1984 and 1985. Data on all patients with 2-vessel disease diagnosed at Emory University who underwent elective angioplasty or coronary surgery in the years 1984 and 1985 were compared. Categoric variables were analyzed by chi-square and continuous variables by unpaired t test. Survival was determined by the Kaplan-Meier method and differences in survival by the Mantel-Cox method. Determinants of survival were determined by Cox model analysis. There were 415 angioplasty patients and 454 surgical patients. Surgical patients were older and had more frequent systemic hypertension, diabetes mellitus, prior myocardial infarction, severe angina and congestive failure, and more significant narrowing in the left anterior descending coronary artery, totally occluded vessels and left ventricular dysfunction than did angioplasty patients. Complete revascularization was achieved more often in surgical patients. There was no difference in Q-wave myocardial infarction in the hospital. No angioplasty patient died compared with 1.1% of surgical patients (p = 0.03). Whereas 5-year survival was 93% in angioplasty patients and 89% in surgical patients (p = 0.11), there was no difference in risk-adjusted survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Financial impact of coronary stenting in emergency for acute coronary syndromes.

PubMed

Nidegger, Delphine; Metz, Damien; Vacter, Christophe; Tassan-Mangina, Sophie; Deschildre, Alain; Gawron, Michel; Bourgeois, Jacqueline

2009-05-01

Since the prospective payment system, health institutions have only specific payments for the emergency care in the emergency room. The direct urgent admissions in coronary care units for acute coronary syndrome (ACS) do not collect this complementary refund. For the patient's stay, hospital is remunerated with fixed national prices which are similar even in case of emergent or planed coronary revascularization when realized. To analyze and compare the financial impact between emergent and planed coronary stenting in the setting of ACS. This retrospective study was based on patients suffering from ACS who experienced emergent coronary stenting during the year 2005. On 154 patients, 127 were age-, sex- and diagnosis-related group (called "groupe homogène de malades" in the French Health Care system)-matched with 127 suffering from same ACS but with planed "ad hoc" coronary stenting. The overall charges (medical and paramedical team, pharmacy, biology, implantable coronary devices, radiology) were compared between the two groups. Mean stay duration was 6.7 days and did not differ between the two groups. Mean financial retributions were significantly higher in the emergent group (7338 euro [6831-7846] IC95 vs 6509 euro [5994-7023]; p=0,02) but with a much more raised consumption (6810 euro [6283-7336] vs 5223 euro [4632-5814]; p=0,001). This overcost was due especially to drugs and biological expenses. The hospitalization payments did not cover the overall expenses for 25% of the patients' stays (N=64) among whom 39 have had emergent coronary stenting (30.7%, p=0.04). Among the different GHM, the most important difference was observed in non-STEMI without complication with a negative receipts/costs ratio for 37.8% of the stay with coronary stenting in emergency. The application of the recent guidelines for coronary revascularization in the management of ACS represents a financial venture for hospital institutions. The engaged charges for emergent coronary stenting

Impact of maternal dexamethasone on coronary PGE2 production and prostaglandin-dependent coronary reactivity

PubMed Central

Volk, Kenneth A.; Lamb, Fred S.; Segar, Jeffrey L.

2012-01-01

Intrauterine growth restriction is associated with increased fetal glucocorticoid exposure and an increased risk of adult coronary artery disease. Coronary arteries from sheep exposed to early gestation dexamethasone (Dex) have increased constriction to angiotensin II (ANG II). Prostaglandin E2 (PGE2) helps maintain coronary dilation, but PGE2 production is acutely decreased by Dex administration. We hypothesized early gestation Dex exposure impairs adult coronary PGE2 production with subsequent increases in coronary reactivity. Dex was administered to ewes at 27–28 days gestation (term 145 days). Coronary reactivity was assessed by wire myography in offspring at 4 mo of age (N = 5 to 7). Coronary smooth muscle cells were cultured and prostaglandin production was measured after 90 min incubation with radiolabeled arachidonate. Coronary myocytes from Dex-exposed lambs had a significant decrease in PGE2 production that was reversed with ANG II incubation. Dex-exposed coronary arteries had increased constriction to ANG II and attenuated dilatation to arachidonic acid, with the greatest difference seen after the endothelium was inactivated by rubbing. Preincubation with the cyclooxygenase (COX) inhibitor indomethacin altered control responses and recapitulated the heightened coronary tone seen following Dex exposure. We conclude that impaired coronary smooth muscle COX-mediated PGE2 production contributes to the coronary dysfunction elicited by early gestation Dex. Programmed inhibition of vasodilatory prostanoid production may link an adverse intrauterine environment with adult coronary artery disease. PMID:22832534

Endothelial effects of hemostatic devices for continuous cardioplegia or minimally invasive operations.

PubMed

Perrault, L P; Menasché, P; Wassef, M; Bidouard, J P; Janiak, P; Villeneuve, N; Jacquemin, C; Bloch, G; Vilaine, J P; Vanhoutte, P M

1996-10-01

Improvements in myocardial protection may include the continuous delivery of normothermic blood cardioplegia. Technical aids are required for optimal visualization of the operative field during the performance of coronary anastomoses if cardioplegia is to be given continuously or during minimally invasive operations. However, the effects of the different hemostatic devices on coronary endothelial function are unknown. We compared the effects on endothelial function of two commonly used hemostatic techniques, coronary clamping and gas jet insufflation, with those of a technique using extravascular balloon occlusion to mimic systolic luminal closure by the surrounding myocardium. The three techniques were applied for 15 minutes on porcine epicardial coronary arteries from explanted hearts. For coronary clamping, standard bulldog clamps were used. Gas jet insufflation was applied by blowing oxygen (12 L/min) tangentially at a 45-degree angle 1 cm away from a 3-mm arteriotomy. Extravascular balloon occlusion was achieved with a needle-tipped silicone loop, the midportion of which, once positioned beneath the coronary artery, was inflated to push a myocardial "cushion" against the back of the vessel until its occlusion. Control rings were taken from the same coronary artery. The endothelial function of control and instrumented arterial rings was then studied in organ chambers filled with modified Krebs-Ringer bicarbonate solution. Contractions to potassium chloride and prostaglandin F2 alpha and endothelium-independent relaxation to sin-1, a nitric oxide donor, were unaffected in all groups. Endothelium-dependent relaxation to serotonin was impaired after clamping and preserved after gas jet insufflation and extravascular balloon occlusion. Maximal endothelium-dependent relaxation to serotonin was as follows: for coronary clamping, 63% +/- 6% versus 87% +/- 3% in controls; for gas jet insufflation, 67% +/- 12% versus 88% +/- 7%; and for extraluminal balloon occlusion

[Comparison of 64 MDCT coronary CTA and coronary angiography in the detection of coronary artery stenosis in low risk patients with stable angina and acute coronary syndrome].

PubMed

Cazalas, G; Sarran, A; Amabile, N; Chaumoitre, K; Marciano-Chagnaud, S; Jacquier, A; Paganelli, F; Panuel, M

2009-09-01

To determine the accuracy of 64 MDCT coronary CTA (CCTA) compared to coronary angiography in low risk patients with stable angina and acute coronary syndrome and determine the number of significant coronary artery stenoses ( 50%) in these patients. Materials and methods. Fifty-five patients underwent CCTA using a 32 MDCT unit with z flying focus allowing the acquisition of 64 slices of 0.6 mm thickness as well as coronary angiography (gold standard). Nine patients were excluded due to prior coronary artery bypass surgery (n=4), insufficient breath hold (n=3), calcium scoring>1000 (n=1) and delay between both examinations over 4 months (n=1). Forty-six patients: 27 males and 19 females were included. CCTA results were compared to coronary angiography per segment and artery with threshold detection of stenoses 50%. The degree of correlation between both examinations was performed using a regression analysis with a Pearson correlation coefficient<0.05 considered significant. The overall accuracy of CCTA was 90%; limitations related to the presence of calcifications, motion artifacts or insufficient vessel opacification. The correlation for all analyzed segments was 96.4%. Thirty-eight of 50 significant stenoses seen on coronary angiography were correctly detected on CCTA. Sensitivity, specificity, PPVC and NPV for detection of stenoses 50% were 76%, 98.3%, 80.3% and 97.7% respectively. Evaluation per segment had a NPV of 96.8% (interventricular and diagonal segments) to 100% (main trunk). Our results for specificity and NPV are similar to reports from the literature. This suggests that CCTA in this clinical setting may replace coronary angiography.

Lasting monitoring of immune state in patients with coronary atherosclerosis

NASA Astrophysics Data System (ADS)

Malinova, Lidia I.; Denisova, Tatyana P.; Tuchin, Valery V.

2007-02-01

Immune state monitoring is an expensive, invasive and sometimes difficult necessity in patients with different disorders. Immune reaction dynamics study in patients with coronary atherosclerosis provides one of the leading components to complication development, clinical course prognosis and treatment and rehabilitation tactics. We've chosen intravenous glucose injection as metabolic irritant in the following four groups of patients: men with proved coronary atherosclerosis (CA), non insulin dependent diabetes mellitus (NIDDM), men hereditary burden by CA and NIDDM and practically healthy persons with longlivers in generation. Immune state parameters such as quantity of leukocytes and lymphocytes, circulating immune complexes levels, serum immunoglobulin levels, HLA antigen markers were studied at 0, 30 and 60 minutes during glucose loading. To obtain continues time function of studied parameters received data were approximated by polynomials of high degree with after going first derivatives. Time functions analyze elucidate principally different dynamics studied parameters in all chosen groups of patients, which couldn't be obtained from discontinuous data compare. Leukocyte and lymphocyte levels dynamics correlated HLA antigen markers in all studied groups. Analytical estimation of immune state in patients with coronary atherosclerosis shows the functional "margin of safety" of immune system state under glucose disturbance. Proposed method of analytical estimation also can be used in immune system monitoring in other groups of patients.

SYNTAX score based on coronary computed tomography angiography may have a prognostic value in patients with complex coronary artery disease: An observational study from a retrospective cohort.

PubMed

Suh, Young Joo; Han, Kyunghwa; Chang, Suyon; Kim, Jin Young; Im, Dong Jin; Hong, Yoo Jin; Lee, Hye-Jeong; Hur, Jin; Kim, Young Jin; Choi, Byoung Wook

2017-09-01

The SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) score is an invasive coronary angiography (ICA)-based score for quantifying the complexity of coronary artery disease (CAD). Although the SYNTAX score was originally developed based on ICA, recent publications have reported that coronary computed tomography angiography (CCTA) is a feasible modality for the estimation of the SYNTAX score.The aim of our study was to investigate the prognostic value of the SYNTAX score, based on CCTA for the prediction of major adverse cardiac and cerebrovascular events (MACCEs) in patients with complex CAD.The current study was approved by the institutional review board of our institution, and informed consent was waived for this retrospective cohort study. We included 251 patients (173 men, mean age 66.0 ± 9.29 years) who had complex CAD [3-vessel disease or left main (LM) disease] on CCTA. SYNTAX score was obtained on the basis of CCTA. Follow-up clinical outcome data regarding composite MACCEs were also obtained. Cox proportional hazards models were developed to predict the risk of MACCEs based on clinical variables, treatment, and computed tomography (CT)-SYNTAX scores.During the median follow-up period of 1517 days, there were 48 MACCEs. Univariate Cox hazards models demonstrated that MACCEs were associated with advanced age, low body mass index (BMI), and dyslipidemia (P < .2). In patients with LM disease, MACCEs were associated with a higher SYNTAX score. In patients with CT-SYNTAX score ≥23, patients who underwent coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention had significantly lower hazard ratios than patients who were treated with medication alone. In multivariate Cox hazards model, advanced age, low BMI, and higher SYNTAX score showed an increased hazard ratio for MACCE, while treatment with CABG showed a lower hazard ratio (P < .2).On the basis of our results, CT-SYNTAX score

Additional Value of Transluminal Attenuation Gradient in CT Angiography to Predict Hemodynamic Significance of Coronary Artery Stenosis

PubMed Central

Stuijfzand, Wynand J.; Danad, Ibrahim; Raijmakers, Pieter G.; Marcu, C. Bogdan; Heymans, Martijn W.; van Kuijk, Cornelis C.; van Rossum, Albert C.; Nieman, Koen; Min, James K.; Leipsic, Jonathon; van Royen, Niels; Knaapen, Paul

2015-01-01

OBJECTIVES The current study evaluates the incremental value of transluminal attenuation gradient (TAG), TAG with corrected contrast opacification (CCO), and TAG with exclusion of calcified coronary segments (ExC) over coronary computed tomography angiogram (CTA) alone using fractional flow reserve (FFR) as the gold standard. BACKGROUND TAG is defined as the contrast opacification gradient along the length of a coronary artery on a coronary CTA. Preliminary data suggest that TAG provides additional functional information. Interpretation of TAG is hampered by multiple heartbeat acquisition algorithms and coronary calcifications. Two correction models have been proposed based on either dephasing of contrast delivery by relating coronary density to corresponding descending aortic opacification (TAG-CCO) or excluding calcified coronary segments (TAG-ExC). METHODS Eighty-five patients with intermediate probability of coronary artery disease were prospectively included. All patients underwent step-and-shoot 256-slice coronary CTA. TAG, TAG-CCO, and TAG-ExC analyses were performed followed by invasive coronary angiography in conjunction with FFR measurements of all major coronary branches. RESULTS Thirty-four patients (40%) were diagnosed with hemodynamically-significant coronary artery disease (i.e., FFR ≤0.80). On a per-vessel basis (n = 253), 59 lesions (23%) were graded as hemodynamically significant, and the diagnostic accuracy of coronary CTA (diameter stenosis ≥50%) was 95%, 75%, 98%, and 54% for sensitivity, specificity, negative predictive value, and positive predictive value, respectively. TAG and TAG-ExC did not discriminate between vessels with or without hemodynamically significant lesions (−13.5 ± 17.1 HU [Hounsfield units] × 10 mm−1 vs. −11.6 ± 13.3 HU × 10 mm−1, p = 0.36; and 13.1 ± 15.9 HU × 10 mm−1 vs. −11.4 ± 11.7 HU × 10 mm−1, p = 0.77, respectively). TAG-CCO was lower in vessels with a hemodynamically-significant lesion (−0

Coronary responses to endothelin-1 and acetylcholine during partial coronary ischaemia and reperfusion in anaesthetized goats.

PubMed

Martínez, Maria Angeles; Fernández, Nuria; Monge, Luis; García-Villalón, Angel Luis; Sanz, Elena; Diéguez, Godofredo

2002-08-01

To examine coronary reactivity to acetylcholine and endothelin-1 (ET-1) during partial ischaemia and reperfusion, flow in the left circumflex coronary artery was measured electromagnetically, and coronary partial ischaemia was induced by stenosis of this artery in anaesthetized goats. In eight animals not treated with N(G)-nitro-l-arginine methyl ester (l-NAME), coronary stenosis reduced coronary flow by 45%, mean arterial pressure by 16% and coronary vascular conductance by 34%. During this ischaemia, coronary vasodilatation to acetylcholine (0.003-0.1 microg) and sodium nitroprusside (SNP; 1-10 microg) was markedly reduced, and coronary vasoconstriction to ET-1 (0.01-0.3 nmol) was attenuated. After 30 min of reperfusion, coronary flow, mean arterial pressure and coronary vascular conductance remained decreased, and the effects of acetylcholine, SNP and ET-1 were as in control animals. In six goats treated with N(G)-nitro-l-arginine methyl ester, coronary stenosis reduced coronary flow by 26% and coronary vascular conductance by 24%, but did not affect mean arterial pressure. During this ischaemia, coronary vasodilatation to acetylcholine and SNP was also markedly reduced, but vasoconstriction to ET-1 was unaffected. After 30 min of reperfusion, coronary flow and coronary vascular conductance remained decreased and mean arterial pressure was normal; in addition, the effects of acetylcholine were lower, those of SNP were similar and those of ET-1 were higher than in control animals. Therefore partial ischaemia reduces the coronary vasodilator reserve and blunts coronary vasoconstriction to ET-1, and reperfusion does not alter the endothelium-dependent and -independent coronary vasodilatation or vasoconstriction to ET-1.

Normothermic and hypothermic models for studying the deleterious effects of hypoxia-reoxygenation on EDHF-mediated relaxation in isolated porcine coronary arteries.

PubMed

Ziberna, Lovro; Lunder, Mojca; Kuzner, Jernej; Drevensek, Gorazd

2009-01-01

The vasomotor response of the coronary artery is altered by hypoxia-reoxygenation (H-R) induced damage. The aim of our study was to compare and evaluate normothermic and hypothermic models which are suitable for future drug studies of vasoprotective action against H-R injury. Porcine coronary arterial rings were isolated and placed in Krebs-Henseleit (K-H) solution. Rings were exposed to normoxic conditions (control group) and two different H-R conditions: the first induced by a 95% N(2)-5% CO(2) gas mixture (40- and 60-min hypoxia) in a normothermic protocol, and the second induced by hypothermic (4 degrees C) hypoxia-reoxygenation in an air-tight beaker filled with K-H solution (24- and 48-hours hypoxia). Reoxygenation was applied by introducing K-H solution aerated with a 95% O(2)-5% CO(2) mixture under normothermic (37 degrees C) conditions. To test the EDHF-mediated relaxation by substance P, rings were first incubated in L-NNA, nitric oxide synthase inhibitor, and indomethacin, cyclooxygenase inhibitor, and then pre-contracted with thromboxane analogue U-46619. Analysis of the maximum relaxation of the arterial rings was performed by one-way ANOVA, followed by Bonferroni's post-test. Distal segments of the coronary artery responded faster to contraction induced by U-46619 and were relaxed by substance P to a greater extent than proximal segments. Maximal relaxations of arterial rings induced by a 10 nM solution of substance P were significantly reduced (p<0.001) from the values for normoxic rings (81.0+/-1.0%, n=30) after 40-min H-R (50.5+/-5.3%, n=30), 60-min H-R (32.1+/-3.5%, n=30), 24-hours hypothermic H-R (56.0+/-2.3%, n=30) and after 48-hours hypothermic H-R (38.5+/-5.1%, n=30). The model employing 40-min normothermic H-R is as effective as 24-hours hypothermic H-R, and 60-min normothermic H-R as 48-hours hypothermic H-R for studying the deleterious effects of H-R on EDHF-mediated relaxation.

Evaluation of cerebral vasomotor reactivity in Parkinson's disease: is there any association with orthostatic hypotension?

PubMed

Zamani, Babak; Mehrabani, Mehrnoush; Fereshtehnejad, Seyed-Mohammad; Rohani, Mohammad

2011-06-01

Our aim was to look for a probable relationship between cerebral vasomotor reactivity (VMR) and orthostatic hypotension (OH) in Parkinson's disease (PD). This study was conducted on 44 patients with PD. Assessment of cerebral VMR was performed by means of transcranial Doppler (TCD) of middle cerebral artery (MCA) before and after a vasodilatory stimulus, carbon dioxide test. Moreover, orthostatic hypotension was evaluated. OH was presented in 12 (27.3%) Parkinson's patients. The average resting blood flow velocity (BFV) in the MCA was 30.20 (SD=9.58)cms(-1) which significantly increased to 46.25 (SD=16.23)cms(-1) after carbon dioxide test (P<0.001). Impaired VMR was observed in 15 (34.1%) of the subjects, while it was not associated with the presence of OH (P=0.770). Evaluation of VMR in patients affected by PD, could assist in early diagnosis of cerebral autonomic dysfunction and prevent its serious consequences prior and more valid to OH. Crown Copyright © 2010. Published by Elsevier B.V. All rights reserved.

Redo coronary bypass grafting for congenital left main coronary atresia: a case report.

PubMed

Yajima, Shin; Toda, Koichi; Nishi, Hiroyuki; Yoshioka, Daisuke; Nakamura, Teruya; Miyagawa, Shigeru; Yoshikawa, Yasushi; Fukushima, Satsuki; Sawa, Yoshiki

2017-05-15

Congenital left main coronary atresia is an extremely rare coronary anomaly. Long-term surgical outcomes and the optimal management strategies for recurrence of ischemia remain uncertain. Herein, we present a case involving successful redo coronary artery bypass grafting for unstable angina 27 years after the initial coronary artery bypass grafting for congenital left main coronary atresia. A 33-year-old woman was referred to our department with unstable angina. At the age of 6, she had undergone coronary artery bypass grafting of the second diagonal branch using the left internal thoracic artery and the obtuse marginal branch using saphenous vein grafting for left main coronary atresia. Although a coronary angiogram showed a patent left internal thoracic artery graft to the second diagonal branch and a patent saphenous vein graft to the obtuse marginal branch, the left anterior descending artery was not being perfused by the grafts because of a disruption of blood flow to the left anterior descending artery from the left internal thoracic artery. Therefore, we performed a redo coronary artery bypass grafting using the in situ right internal thoracic artery to the first diagonal branch, which was to be connected to the left anterior descending artery, resulting in amelioration of the ischemia of the left anterior wall. The patient was discharged 10 days after the operation and has been in good health for over 3 years without recurrence of chest symptoms. Coronary revascularization using a saphenous vein and left internal thoracic artery grafts is effective in achieving an adequate blood supply to the distal coronary arteries, and this effect can last for decades. However, careful follow-up is necessary because recurrent myocardial ischemia due to the development of a coronary artery occlusion may occur in adulthood.

A randomized-controlled trial examining the effects of reflexology on anxiety of patients undergoing coronary angiography.

PubMed

Molavi Vardanjani, Mehdi; Masoudi Alavi, Negin; Razavi, Narges Sadat; Aghajani, Mohammad; Azizi-Fini, Esmail; Vaghefi, Seied Morteza

2013-09-01

The anxiety reduction before coronary angiography has clinical advantages and is one of the objectives of nursing. Reflexology is a non-invasive method that has been used in several clinical situations. Applying reflexology might have effect on the reduction of anxiety before coronary angiography. The aim of this randomized clinical trial was to investigate the effect of reflexology on anxiety among patients undergoing coronary angiography. This trial was conducted in Shahid Beheshti Hospital, in Kashan, Iran. One hundred male patients who were undergoing coronary angiography were randomly enrolled into intervention and placebo groups. The intervention protocol was included 30 minutes of general foot massage and the stimulation of three reflex points including solar plexus, pituitary gland, and heart. The placebo group only received the general foot massage. Spielbergers state trait anxiety inventory was used to assess the anxiety experienced by patients. Data was analyzed using Man-Witney, Wilcoxon and Chi-square tests. The stepwise multiple regressions used to analyze the variables that are involved in anxiety reduction. The mean range of anxiety decreased from 53.24 to 45.24 in reflexology group which represented 8 score reduction (P = 0.0001). The reduction in anxiety was 5.9 score in placebo group which was also significant (P = 0.0001). The anxiety reduction was significantly higher in reflexology group (P = 0.014). The stepwise multiple regression analysis showed that doing reflexology can explain the 7.5% of anxiety reduction which made a significant model. Reflexology can decrease the anxiety level before coronary angiography. Therefore, reflexology before coronary angiography is recommended.

Stress echocardiography for the diagnosis of coronary artery disease: an evidence-based analysis.

PubMed

2010-01-01

In July 2009, the Medical Advisory Secretariat (MAS) began work on Non-Invasive Cardiac Imaging Technologies for the Diagnosis of Coronary Artery Disease (CAD), an evidence-based review of the literature surrounding different cardiac imaging modalities to ensure that appropriate technologies are accessed by patients suspected of having CAD. This project came about when the Health Services Branch at the Ministry of Health and Long-Term Care asked MAS to provide an evidentiary platform on effectiveness and cost-effectiveness of non-invasive cardiac imaging modalities.After an initial review of the strategy and consultation with experts, MAS identified five key non-invasive cardiac imaging technologies for the diagnosis of CAD. Evidence-based analyses have been prepared for each of these five imaging modalities: cardiac magnetic resonance imaging, single photon emission computed tomography, 64-slice computed tomographic angiography, stress echocardiography, and stress echocardiography with contrast. For each technology, an economic analysis was also completed (where appropriate). A summary decision analytic model was then developed to encapsulate the data from each of these reports (available on the OHTAC and MAS website).The Non-Invasive Cardiac Imaging Technologies for the Diagnosis of Coronary Artery Disease series is made up of the following reports, which can be publicly accessed at the MAS website at: www.health.gov.on.ca/mas">www.health.gov.on.ca/mas or at www.health.gov.on.ca/english/providers/program/mas/mas_about.htmlSINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY FOR THE DIAGNOSIS OF CORONARY ARTERY DISEASE: An Evidence-Based AnalysisSTRESS ECHOCARDIOGRAPHY FOR THE DIAGNOSIS OF CORONARY ARTERY DISEASE: An Evidence-Based AnalysisSTRESS ECHOCARDIOGRAPHY WITH CONTRAST FOR THE DIAGNOSIS OF CORONARY ARTERY DISEASE: An Evidence-Based Analysis64-Slice Computed Tomographic Angiography for the Diagnosis of Coronary Artery Disease: An Evidence-Based Analysis

[Experimental evaluation of the role of the coronary sinus pressure in the regulation of coronary return volume via the coronary sinus. Surgical considerations in atrio-pulmonary diversion procedures].

PubMed

Fantidis, P; Fernández Ruiz, M A; Madero Jarabo, R; Moreno Granados, F; Cordovilla Zurdo, G; Sanz Galeote, E

1990-11-01

In order to find out the validity of the vascular waterfall mechanism in coronary venous circulation, the role of coronary sinus pressure in the regulation of coronary return volume via the coronary sinus is studied in healthy animals. An experimental model of pressure regulation in the coronary sinus was prepared, and aortic pressure, EKG and the cardiac output (measured by thermodilution) were recorded. The return volume via the coronary sinus was measured at coronary sinus pressure of 10 or less, 15, 20, and 25 mmHg or more, for a total of 36 determinations. Increased coronary sinus pressure did not produce significant changes in aortic pressure, heart rate, cardiac index or coronary return volume via coronary sinus. When coronary sinus pressure was 25 mmHg or more, there was a significant decline in the average of coronary return volume via coronary sinus. Nevertheless, stepwise variant regression showed that the coronary sinus pressure per se does not condition the volume of coronary return via the coronary sinus. Our results suggest that in the healthy animals, the vascular waterfall mechanism in coronary venous circulation is not valid. Our results suggest that in the correction of congenital cardiac malformations using atriopulmonary anastomosis procedures, employing techniques that ensure coronary sinus drainage into the left atrium, in order to avoid the hemodynamic repercussions attributable to the vascular waterfall mechanism, is not justified.

Comparison of the management and in-hospital outcomes of acute coronary syndrome patients in Australia and New Zealand: results from the binational SNAPSHOT acute coronary syndrome 2012 audit.

PubMed

Ellis, C; Hammett, C; Ranasinghe, I; French, J; Briffa, T; Devlin, G; Elliott, J; Lefkovitz, J; Aliprandi-Costa, B; Astley, C; Redfern, J; Howell, T; Carr, B; Lintern, K; Bloomer, S; Farshid, A; Matsis, P; Hamer, A; Williams, M; Troughton, R; Horsfall, M; Hyun, K; Gamble, G; White, H; Brieger, D; Chew, D

2015-05-01

We aimed to assess differences in patient management, and outcomes, of Australian and New Zealand patients admitted with a suspected or confirmed acute coronary syndrome (ACS). We used comprehensive data from the binational Australia and New Zealand ACS 'SNAPSHOT' audit, acquired on individual patients admitted between 00.00 h on 14 May 2012 to 24.00 h on 27 May 2012. There were 4387 patient admissions, 3381 (77%) in Australia and 1006 (23%) in New Zealand; Australian patients were slightly younger (67 vs 69 years, P = 0.0044). Of the 2356 patients with confirmed ACS, Australian patients were at a lower cardiovascular risk with a lower median Global Registry Acute Coronary Events score (147 vs 154 P = 0.0008), but as likely to receive an invasive coronary angiogram (58% vs 54%, P = 0.082), or revascularisation with percutaneous coronary intervention (32% vs 31%, P = 0.92) or coronary artery bypass graft surgery (7.0% vs 5.6%, P = 0.32). Of the 1937 non-segment elevation myocardial infarction/unstable angina pectoris (NSTEMI/UAP) patients, Australian patients had a shorter time to angiography (46 h vs 67 h, P < 0.0001). However, at discharge, Australian NSTEMI/UAP survivors were less likely to receive aspirin (84% vs 89%, P = 0.0079, a second anti-platelet agent (57% vs 63%, P = 0.050) or a beta blocker (67% vs 77%, P = 0.0002). In-hospital death rates were not different (2.7% vs 3.2%, P = 0.55) between Australia and New Zealand. Overall more similarities were seen, than differences, in the management of suspected or confirmed ACS patients between Australia and New Zealand. However, in several management areas, both countries could improve the service delivery to this high-risk patient group. © 2015 Royal Australasian College of Physicians.

Head-to-head comparison of adaptive statistical and model-based iterative reconstruction algorithms for submillisievert coronary CT angiography.

PubMed

Benz, Dominik C; Fuchs, Tobias A; Gräni, Christoph; Studer Bruengger, Annina A; Clerc, Olivier F; Mikulicic, Fran; Messerli, Michael; Stehli, Julia; Possner, Mathias; Pazhenkottil, Aju P; Gaemperli, Oliver; Kaufmann, Philipp A; Buechel, Ronny R

2018-02-01

Iterative reconstruction (IR) algorithms allow for a significant reduction in radiation dose of coronary computed tomography angiography (CCTA). We performed a head-to-head comparison of adaptive statistical IR (ASiR) and model-based IR (MBIR) algorithms to assess their impact on quantitative image parameters and diagnostic accuracy for submillisievert CCTA. CCTA datasets of 91 patients were reconstructed using filtered back projection (FBP), increasing contributions of ASiR (20, 40, 60, 80, and 100%), and MBIR. Signal and noise were measured in the aortic root to calculate signal-to-noise ratio (SNR). In a subgroup of 36 patients, diagnostic accuracy of ASiR 40%, ASiR 100%, and MBIR for diagnosis of coronary artery disease (CAD) was compared with invasive coronary angiography. Median radiation dose was 0.21 mSv for CCTA. While increasing levels of ASiR gradually reduced image noise compared with FBP (up to - 48%, P < 0.001), MBIR provided largest noise reduction (-79% compared with FBP) outperforming ASiR (-59% compared with ASiR 100%; P < 0.001). Increased noise and lower SNR with ASiR 40% and ASiR 100% resulted in substantially lower diagnostic accuracy to detect CAD as diagnosed by invasive coronary angiography compared with MBIR: sensitivity and specificity were 100 and 37%, 100 and 57%, and 100 and 74% for ASiR 40%, ASiR 100%, and MBIR, respectively. MBIR offers substantial noise reduction with increased SNR, paving the way for implementation of submillisievert CCTA protocols in clinical routine. In contrast, inferior noise reduction by ASiR negatively affects diagnostic accuracy of submillisievert CCTA for CAD detection. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.

Vasomotor symptoms and cardiovascular events in postmenopausal women

PubMed Central

Szmuilowicz, Emily D.; Manson, JoAnn E.; Rossouw, Jacques E.; Howard, Barbara V.; Margolis, Karen L.; Greep, Nancy C.; Brzyski, Robert G.; Stefanick, Marcia L.; O'Sullivan, Mary Jo; Wu, Chunyuan; Allison, Matthew; Grobbee, Diederick E.; Johnson, Karen C.; Ockene, Judith K.; Rodriguez, Beatriz L.; Sarto, Gloria E.; Vitolins, Mara Z.; Seely, Ellen W.

2010-01-01

Objective Emerging evidence suggests that women with menopausal vasomotor symptoms (VMS) have increased cardiovascular disease (CVD) risk as measured by surrogate markers. We investigated the relationships between VMS and clinical CVD events and all-cause mortality in the Women's Health Initiative Observational Study (WHI-OS). Methods We compared the risk of incident CVD events and all-cause mortality between four groups of women (total N=60,027): (1) No VMS at menopause onset and no VMS at WHI-OS enrollment (no VMS [referent group]); (2) VMS at menopause onset, but not at WHI-OS enrollment (early VMS); (3) VMS at both menopause onset and WHI-OS enrollment (persistent VMS [early and late]); and (4) VMS at WHI-OS enrollment, but not at menopause onset (late VMS). Results For women with early VMS (N=24,753), compared to no VMS (N=18,799), hazard ratios (HRs) and 95% confidence intervals (CIs) in fully-adjusted models were: major CHD, 0.94 (0.84, 1.06); stroke, 0.83 (0.72, 0.96); total CVD, 0.89 (0.81, 0.97); and all-cause mortality, 0.92 (0.85, 0.99). For women with persistent VMS (N=15,084), there was no significant association with clinical events. For women with late VMS (N=1,391) compared to no VMS, HRs and 95% CIs were: major CHD, 1.32 (1.01, 1.71); stroke, 1.14 (0.82, 1.59); total CVD, 1.23 (1.00, 1.52); and all-cause mortality, 1.29 (1.08, 1.54). Conclusions Early VMS were not associated with increased CVD risk. Rather, early VMS were associated with decreased risk of stroke, total CVD events, and all-cause mortality. Late VMS were associated with increased CHD risk and all-cause mortality. The predictive value of VMS for clinical CVD events may vary with onset of VMS at different stages of menopause. Further research examining the mechanisms underlying these associations is needed. Future studies will also be necessary to investigate whether VMS that develop for the first time in the later postmenopausal years represent a pathophysiologic process distinct

Safety of veralipride for the treatment of vasomotor symptoms of menopause.

PubMed

Valencia, Marcelino Hernández; Arias, María de Jesús Vega; González, Cuauhtémoc Celis; Marín, Imelda Hernández; González, Juan Humberto Martín; Campos, Enrique Rafael Morcate; Rodríguez, María Antonia Basavilvazo; Álvarez, Ignacio Morales; Vargas, María Antonia Valdés; Flores, José Braulio Everardo Otero; Haro, Samuel Santoyo; Bonilla, Manuel Cortes; Escudero, Roberto Bernardo; Campero, Rosalba Alonso

2014-05-01

Veralipride is a nonhormonal option for the treatment of vasomotor symptoms of menopause. Incidence of adverse events in a Mexican population and drug compliance according to correct use were evaluated. We carried out a longitudinal, prospective, and analytical study in Mexican women who received veralipride to treat symptoms of menopause from 2011 to 2012. There were 386 treatment cycles; 272 were assigned to dosing schedule 1, which included 20 days of treatment with 10 days of suspension, and 114 were assigned to dosing schedule 2, which included 5 days of treatment and 2 days of suspension. A total of 57 adverse events were registered during the 386-month treatment. For the 20 × 10 dosing schedule, the highest incidence was observed for anxiety (2.2%), drowsiness, and weakness (1.5%); for the 5 × 2 dosing schedule, the highest incidence was observed for drowsiness (5.3%) and headache (2.6%). The Hamilton Depression Rating Scale was used to assess the presence and severity of depression; improvement was noted. The Unified Parkinson's Disease Rating Scale was used to assess neurological movement disorders; no adverse neurological events were detected. Based on the assessments of both women and physicians, the highest frequency was observed for "very satisfied" (45.5% and 52.3%, respectively), followed by "satisfied" (23.9% and 27.3%, respectively). Both dosing schedules show acceptable safety profiles for up to 6 months of use when used according to the contraindications in the current prescribing information for standard use (2012) and recent medical literature.

An angiographic technique for coronary fractional flow reserve measurement: in vivo validation.

PubMed

Takarada, Shigeho; Zhang, Zhang; Molloi, Sabee

2013-03-01

Fractional flow reserve (FFR) is an important prognostic determinant in a clinical setting. However, its measurement currently requires the use of invasive pressure wire, while an angiographic technique based on first-pass distribution analysis and scaling laws can be used to measure FFR using only image data. Eight anesthetized swine were instrumented with flow probe on the proximal segment of the left anterior descending (LAD) coronary arteries. Volumetric blood flow from the flow probe (Qp), coronary pressure (Pa) and right atrium pressure (Pv) were continuously recorded. Flow probe-based FFR (FFRq) was measured from the ratio of flow with and without stenosis. To determine the angiography-based FFR (FFRa), the ratio of blood flow in the presence of a stenosis (QS) to theoretically normal blood flow (QN) was calculated. A region of interest in the LAD arterial bed was drawn to generate time-density curves using angiographic images. QS was measured using a time-density curve and the assumption that blood was momentarily replaced with contrast agent during the injection. QN was estimated from the total coronary arterial volume using scaling laws. Pressure-wire measurements of FFR (FFRp), which was calculated from the ratio of distal coronary pressure (Pd) divided by proximal pressure (Pa), were continuously obtained during the study. A total of 54 measurements of FFRa, FFRp, and FFRq were taken. FFRa showed a good correlation with FFRq (FFRa = 0.97 FFRq +0.06, r(2) = 0.80, p < 0.001), although FFRp overestimated the FFRq (FFRp = 0.657 FFRq + 0.313, r(2) = 0.710, p < 0.0001). Additionally, the Bland-Altman analysis showed a close agreement between FFRa and FFRq. This angiographic technique to measure FFR can potentially be used to evaluate both anatomical and physiological assessments of a coronary stenosis during routine diagnostic cardiac catheterization that requires no pressure wires.

Early Results of Coronary Endarterectomy Combined with Coronary Artery Bypass Grafting in Patients with Diffused Coronary Artery Disease

PubMed Central

Chi, Li-Qun; Zhang, Jian-Qun; Kong, Qing-Yu; Xiao, Wei; Liang, Lin; Chen, Xin-Liang

2015-01-01

Background: It is still a challenge for the cardiac surgeons to achieve adequate revascularization for diffused coronary artery disease (CAD). Coronary endarterectomy (CE) offers an alternative choice of coronary artery reconstruction and revascularization. In this study, short-term result of CE combined with coronary artery bypass graft (CABG) was discussed in the treatment for the diffused CAD. Methods: From January 2012 to April 2014, 221 cases of CABG were performed by the same surgeon in our unit. Among these cases, 38 cases of CE + CABG were performed, which was about 17.2% (38/221) of the cohort. All these patients were divided into two groups: CE + CABG group (Group A) and CABG alone group (Group B). All clinical data were compared between the two groups, and postoperative complications and in-hospital mortality were analyzed. The categorical and continuous variables were analyzed by Chi-square test and Student's t-test respectively. Results: Diabetes mellitus, hypertension, hyperlipidemia, and peripheral vascular disease were more common in group A. In this cohort, a total of 50 vessels were endarterectomized. Among them, CE was performed on left anterior descending artery in 11 cases, on right coronary artery in 29 cases, on diagonal artery in 3 cases, on intermediate artery in 2 cases, on obtuse marginal artery in 5 cases. There was no hospital mortality in both groups. The intro-aortic balloon pump was required in 3 cases in Group A (3/38), which was more often than that in Group B (3/183). At the time of follow-up, coronary computed tomography angiogram showed all the grafts with CE were patent (50/50). There is no cardio-related mortality in both groups. All these patients were free from coronary re-intervention. Conclusions: Coronary endarterectomy + CABG can offer satisfactory result for patients with diffused CAD in a short-term after the operation. PMID:26021501

Multiple Giant Coronary Artery Aneurysms

PubMed Central

Marla, Rammohan; Ebel, Rachel; Crosby, Marcus; Almassi, G. Hossein

2009-01-01

Coronary artery aneurysms are rare, and giant coronary artery aneurysms are even rarer. We describe a patient who had giant coronary aneurysms of the right, left circumflex, and left anterior descending coronary arteries. The aneurysms were successfully treated with surgical intervention. To the best of our knowledge, ours is the 1st report of giant aneurysms involving all 3 major coronary arteries. PMID:19568397

Rationale and design of the Clinical Evaluation of Magnetic Resonance Imaging in Coronary heart disease 2 trial (CE-MARC 2): A prospective, multicenter, randomized trial of diagnostic strategies in suspected coronary heart disease

PubMed Central

Ripley, David P.; Brown, Julia M.; Everett, Colin C.; Bijsterveld, Petra; Walker, Simon; Sculpher, Mark; McCann, Gerry P.; Berry, Colin; Plein, Sven; Greenwood, John P.

2015-01-01

Background A number of investigative strategies exist for the diagnosis of coronary heart disease (CHD). Despite the widespread availability of noninvasive imaging, invasive angiography is commonly used early in the diagnostic pathway. Consequently, approximately 60% of angiograms reveal no evidence of obstructive coronary disease. Reducing unnecessary angiography has potential financial savings and avoids exposing the patient to unnecessary risk. There are no large-scale comparative effectiveness trials of the different diagnostic strategies recommended in international guidelines and none that have evaluated the safety and efficacy of cardiovascular magnetic resonance. Trial Design CE-MARC 2 is a prospective, multicenter, 3-arm parallel group, randomized controlled trial of patients with suspected CHD (pretest likelihood 10%-90%) requiring further investigation. A total of 1,200 patients will be randomized on a 2:2:1 basis to receive 3.0-T cardiovascular magnetic resonance–guided care, single-photon emission computed tomography–guided care (according to American College of Cardiology/American Heart Association appropriate-use criteria), or National Institute for Health and Care Excellence guidelines–based management. The primary (efficacy) end point is the occurrence of unnecessary angiography as defined by a normal (>0.8) invasive fractional flow reserve. Safety of each strategy will be assessed by 3-year major adverse cardiovascular event rates. Cost-effectiveness and health-related quality-of-life measures will be performed. Conclusions The CE-MARC 2 trial will provide comparative efficacy and safety evidence for 3 different strategies of investigating patients with suspected CHD, with the intension of reducing unnecessary invasive angiography rates. Evaluation of these management strategies has the potential to improve patient care, health-related quality of life, and the cost-effectiveness of CHD investigation. PMID:25497243

Growth Hormone-Releasing Peptide Ghrelin Inhibits Homocysteine-Induced Endothelial Dysfunction in Porcine Coronary Arteries and Human Endothelial Cells

PubMed Central

Hedayati, Nasim; Annambhotla, Suman; Jiang, Jun; Wang, Xinwen; Chai, Hong; Lin, Peter H.; Yao, Qizhi; Chen, Changyi

2009-01-01

Objective Ghrelin, a novel growth-hormone releasing peptide, is implicated to play a protective role in cardiovascular tissues. However, it is not clear whether ghrelin protects vascular tissues from injury secondary to risk factors such as homocysteine (Hcy). The purpose of this study was to investigate the effect and potential mechanisms of ghrelin on Hcy-induced endothelial dysfunction. Methods Porcine coronary artery rings were incubated for 24 hours with ghrelin (100 ng/mL), Hcy (50 μM), or ghrelin plus Hcy. Endothelial vasomotor function was evaluated using the myograph tension model. The response to thromboxane A2 analog U466419, bradykinin, and sodium nitroprusside (SNP) was analyzed. Endothelial nitric oxide synthase (eNOS) expression was determined using real time PCR and immunohistochemistry staining, and superoxide anion production by lucigenin-enhanced chemiluminescence analysis. Human coronary artery endothelial cells (HCAECs) were treated with different concentrations of Hcy, ghrelin, and/or anti-ghrelin receptor (GHS-R1a) antibody for 24 hours, eNOS protein levels were determined by western blot analysis. Results Maximal contraction with U466419 and endothelium-independent vasorelaxation with SNP were not different among the four groups. However, endothelium-dependent vasorelaxation with bradykinin (10-6M) was significantly reduced by 34% with Hcy compared with controls (P<0.05). Addition of ghrelin to Hcy had a protective effect, with 61.6% relaxation, similar to controls (64.7%). Hcy significantly reduced eNOS expression, while ghrelin co-treatment effectively restored eNOS expression to the control levels. Superoxide anion levels, which were increased by 100% with Hcy, returned to control levels with ghrelin co-treatment. Ghrelin also effectively blocked Hcy-induced decrease of eNOS protein levels in HCAECs in a concentration dependent manner. Anti-ghrelin receptor antibody effectively inhibited ghrelin’s effect. Conclusions Ghrelin has a

Diagnostic yield and accuracy of coronary CT angiography after abnormal nuclear myocardial perfusion imaging.

PubMed

Meinel, Felix G; Schoepf, U Joseph; Townsend, Jacob C; Flowers, Brian A; Geyer, Lucas L; Ebersberger, Ullrich; Krazinski, Aleksander W; Kunz, Wolfgang G; Thierfelder, Kolja M; Baker, Deborah W; Khan, Ashan M; Fernandes, Valerian L; O'Brien, Terrence X

2018-06-15

We aimed to determine the diagnostic yield and accuracy of coronary CT angiography (CCTA) in patients referred for invasive coronary angiography (ICA) based on clinical concern for coronary artery disease (CAD) and an abnormal nuclear stress myocardial perfusion imaging (MPI) study. We enrolled 100 patients (84 male, mean age 59.6 ± 8.9 years) with an abnormal MPI study and subsequent referral for ICA. Each patient underwent CCTA prior to ICA. We analyzed the prevalence of potentially obstructive CAD (≥50% stenosis) on CCTA and calculated the diagnostic accuracy of ≥50% stenosis on CCTA for the detection of clinically significant CAD on ICA (defined as any ≥70% stenosis or ≥50% left main stenosis). On CCTA, 54 patients had at least one ≥50% stenosis. With ICA, 45 patients demonstrated clinically significant CAD. A positive CCTA had 100% sensitivity and 84% specificity with a 100% negative predictive value and 83% positive predictive value for clinically significant CAD on a per patient basis in MPI positive symptomatic patients. In conclusion, almost half (48%) of patients with suspected CAD and an abnormal MPI study demonstrate no obstructive CAD on CCTA.

Coronary vasodilation by the use of sublingual nitroglycerin using 64-slice dual-source coronary computed tomography angiography.

PubMed

Okada, Munemasa; Nakashima, Yoshiteru; Nomura, Takafumi; Miura, Toshiro; Nao, Tomoko; Yoshimura, Masayuki; Sano, Yuichi; Matsunaga, Naofumi

2015-03-01

Sublingual nitroglycerin capsules or spray is routinely used to treat anginal attacks and to maximally dilate the epicardial coronary arteries during coronary angiography. These dilated coronary vessels have an advantage, but increased heart rates were disadvantageous for coronary computed tomography angiography (CTA). The influence of applying nitroglycerin was analyzed regarding the coronary diameter, coronary luminal attenuation, evaluable number of coronary segments, heart rate (HR), HR variability, the optimal reconstruction phase, and image scoring of CTA in the same patients using a 64-slice dual-source CT. Fifty-two patients with atypical chest pain underwent coronary CTA before and after the administration of sublingual nitroglycerin without heart rate control. The coronary diameter and luminal attenuation were measured on short-axial images in each coronary segment. The coronary vasodilation ratios (VRs) were calculated from the coronary diameters at the same location before and after the use of nitroglycerin. The local institutional review board approved this study and written informed consent was obtained from all the patients. No significant differences were noted in the HR variability or optimal reconstruction phase, despite an increase in HR after the use of nitroglycerin. Nitroglycerin significantly enlarged the coronary artery diameter, and VRs of each coronary segment ranged from 7.54% to 22.26%. As compared with baseline coronary diameter, VRs of minor segments (16.91%) were significantly larger than those of major segments (11.35%), and the magnitude of VR correlated with the baseline coronary diameter (r=-0.48, p<0.001). Coronary luminal attenuation significantly increased due to additional administration of contrast material after the use of nitroglycerin (p<0.01), but no significant difference was noted in the image quality after the use of nitroglycerin. Sublingual nitroglycerin significantly enlarged the coronary diameters, especially in

Invasive strategy for treatment of myocardial infarction.

PubMed

Höfling, B; von Pölnitz, A

1990-01-01

The classical approach to the treatment of acute myocardial infarction (MI) has been one of stabilization and complication management. In an effort to optimize treatment, the initiation of the cardiac care unit and the use of antiarrhythmic therapy have succeeded in lowering the mortality rate substantially. More modern concepts are aimed at limiting infarct size and preserving myocardial function. These aims can be achieved medically using intravenous (i.v.) thrombolysis or invasively either with intracoronary (i.c.) thrombolysis, percutaneous transluminal coronary angioplasty (PTCA), or bypass surgery. Although i.c. thrombolysis is more effective than the i.v. route, the necessity for acute coronary catheterization makes it incompatible and difficult for routine use, and thus is usually reserved for cases in which i.v. lysis has failed. Intravenous thrombolysis is becoming the standard approach to MI, and the remaining questions are those of which drug and dosage are optimal and how to approach the patient after thrombolysis. In this regard, we favor a symptom-guided approach, as shown by the TIMI-IIA and European cooperative studies. In patients with ongoing ischemia postlysis, heart catheterization is indicated and a decision regarding PTCA or surgery is then made, depending on anatomy. In patients remaining stable after acute lysis, a predischarge stress may help in selecting patients requiring catheterization. As an alternative invasive approach to acute MI, PTCA may be the quickest and most effective method to recanalize a vessel, but, again, logistical problems make it incompatible in the acute setting. The same is true for bypass surgery, and although extensive improvements have been made in intraoperative myocardial preservation so that a 2% mortality is achievable, it is reserved for patients with extensive ischemia and anatomy unsuitable for PTCA (extensive multivessel or left main disease).

An integrated approach to coronary heart disease diagnosis and clinical management.

PubMed

Infante, Teresa; Forte, Ernesto; Schiano, Concetta; Cavaliere, Carlo; Tedeschi, Carlo; Soricelli, Andrea; Salvatore, Marco; Napoli, Claudio

2017-01-01

The major issue in coronary heart disease (CHD) diagnosis and management is that symptoms onset in an advanced state of disease. Despite the availability of several clinical risk scores, the prediction of cardiovascular events is lacking, and many patients at risk are not well stratified according to the canonical risk factors alone. Therefore, adequate risk assessment remains the most challenging issue. Recently, the integration of imaging data with biochemical markers in a radiogenomic framework has been proposed in many fields of medicine as well as in cardiology. Multimodal imaging and advanced processing techniques can provide both direct (e.g., remodeling index, calcium score, total plaque volume, plaque burden) and indirect (e.g., myocardial perfusion index, coronary flow reserve) imaging features of CHD. Furthermore, the identification of novel non-invasive biochemical markers, mainly focused on plasma and/or serum samples, has increased the specificity of findings, reflecting several pathophysiological pathways of atherosclerosis, the principal actor in CHD. In this context, a multifaced approach, derived from the strengths of all these modalities, appears promising for finer risk stratification and treatment strategies, facilitating the decision-making and clinical management of patients. This review underlines the role of different imaging modalities in the quantification of coronary atherosclerosis and describes novel blood-based markers that could improve diagnosis and have a better predictive value in CHD.

Congenital anomalous aortic origins of the coronary arteries in adults: a Tunisian coronary arteriography study.

PubMed

Ouali, Sana; Neffeti, Elyes; Sendid, Karim; Elghoul, Karima; Remedi, Fahmi; Boughzela, Essia

2009-03-01

There is a lack of Tunisian data on the frequency and clinical significance of different coronary artery anomalies. All patients who underwent coronary angiography from March 1996 to December 2006 were considered. Only patients with congenital anomalous aortic origin of the coronary artery were included. Among 7330adult patients who underwent diagnostic coronary angiography, 20 (0.27%) patients (13men; mean age 53.3years) had anomalies of the coronary artery origin. The right coronary artery was the vessel involved most frequently (n=10); it originated separately from the left sinus of Valsalva (SV) in three patients and from the posterior sinus of Valsalva in one patient. In the other patients, it arose from the left main coronary artery or its branches in a single coronary artery originating from the left sinus of Valsalva. Isolated anomalous left circumflex artery was the second most frequent anomaly (n=6). Isolated anomalous left anterior descending artery was seen in one patient. A single coronary artery arising from the right SV was seen in three patients. Atheroslerotic lesions were seen in eight cases. Four patients underwent coronary revascularization; the remainder received medical management. All 20 patients are alive and had an uneventful follow-up (mean 34.2months). In Tunisia, the incidence of congenital anomalous aortic origin of the coronary artery in adults is 0.27%. The right coronary artery is involved most frequently. Medical management seems promising.

Totally Endoscopic Coronary Artery Bypass for Anomalous Origin of Right Coronary Artery.

PubMed

Kuo, Chia-Cheng; Hsing, Chung-Hsi; Cheng, Bor-Chih

2017-01-01

Anomalous origin of the right coronary artery (ARCA) from the left Valsalva sinus is a rare but known cause of sudden cardiac death. Surgical revascularization techniques include coronary artery bypass grafting, unroofing, and reimplantation. We report 4 patients who underwent robot-assisted totally endoscopic coronary artery bypass (TECAB) for ARCA as an alternative surgical option. In 3 patients, a single aortocoronary saphenous vein bypass was performed, and in 1 patient the right internal mammary artery was used. All grafts are patent as shown by computed tomographic angiography or cardiac catheterization. We claim that totally endoscopic coronary artery bypass is feasible and safe for anomalous origin of the right coronary artery. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Usefulness of layer-specific strain for identifying complex CAD and predicting the severity of coronary lesions in patients with non-ST-segment elevation acute coronary syndrome: Compared with Syntax score.

PubMed

Zhang, Li; Wu, Wei-Chun; Ma, Hong; Wang, Hao

2016-11-15

-operating characteristic curve analysis, endocardial GLS and TLS demonstrated the highest area under curve, showing better diagnostic accuracy (endocardial GLS: value<-21.35% had 72% sensitivity, 84% specificity and area under the curve ¼0.846; endocardial TLS: value<-20.15% had 72% sensitivity, 88% specificity and area under the curve ¼0.852) than GCS, TCS, mid-myocardial and epicardial GLS, and TLS(all, P<0.05). Strains, particularly endocardial GLS and TLS measurement by 2DSTE might enable a non-invasive method to identify complex CAD and predict the severity of coronary lesions in patients with NSTE-ACS. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Extremely Low Birth Weight Preterm Infants Lack Vasomotor Response in Relationship to Cold Body Temperatures at Birth

PubMed Central

Knobel, Robin B.; Holditch-Davis, Diane; Schwartz, Todd A.; Wimmer, John E.

2009-01-01

Objective This study evaluated peripheral vasoconstriction in ELBW infants when body temperature decreased during the first 12-hours of life. Design An exploratory, within-subjects design with 10 ELBW infants. Abdominal and foot temperatures were measured every minute. Peripheral vasoconstriction (abdominal > peripheral temperature by 2° C) and abdominal-peripheral temperature difference were also evaluated. Results Abdominal and peripheral temperatures were significantly correlated within each infant. One 880 g infant exhibited isolated peripheral vasoconstriction; a 960 g infant had abdominal temperatures more than 1° C higher than peripheral temperatures. Eight smaller infants exhibited no peripheral vasoconstriction and spent most of their observations with peripheral greater than abdominal temperatures. In 8 infants, mean temperature difference was significantly higher when abdominal temperature was less than 36.5° C. Conclusion Most ELBW infants did not exhibit peripheral vasoconstriction during their first 12-hours of life, despite low temperatures. ELBW infants’ vasomotor control may be immature during this period. PMID:19626030

Gender differences in response to cold pressor test assessed with velocity-encoded cardiovascular magnetic resonance of the coronary sinus.

PubMed

Moro, Pierre-Julien; Flavian, Antonin; Jacquier, Alexis; Kober, Frank; Quilici, Jacques; Gaborit, Bénédicte; Bonnet, Jean-Louis; Moulin, Guy; Cozzone, Patrick J; Bernard, Monique

2011-09-23

Gender-specific differences in cardiovascular risk are well known, and current evidence supports an existing role of endothelium in these differences. The purpose of this study was to assess non invasively coronary endothelial function in male and female young volunteers by myocardial blood flow (MBF) measurement using coronary sinus (CS) flow quantification by velocity encoded cine cardiovascular magnetic resonance (CMR) at rest and during cold pressor test (CPT). Twenty-four healthy volunteers (12 men, 12 women) underwent CMR in a 3 Tesla MR imager. Coronary sinus flow was measured at rest and during CPT using non breath-hold velocity encoded phase contrast cine-CMR. Myocardial function and morphology were acquired using a cine steady-state free precession sequence. At baseline, mean MBF was 0.63 ± 0.23 mL·g⁻¹·min⁻¹ in men and 0.79 ± 0.21 mL·g⁻¹·min⁻¹ in women. During CPT, the rate pressure product in men significantly increased by 49 ± 36% (p < 0.0001) and in women by 52 ± 22% (p < 0.0001). MBF increased significantly in both men and women by 0.22 ± 0.19 mL·g⁻¹·min⁻¹ (p = 0.0022) and by 0.73 ± 0.43 mL·g⁻¹·min⁻¹ (p = 0.0001), respectively. The increase in MBF was significantly higher in women than in men (p = 0.0012). CMR coronary sinus flow quantification for measuring myocardial blood flow revealed a higher response of MBF to CPT in women than in men. This finding may reflect gender differences in endothelial-dependent vasodilatation in these young subjects. This non invasive rest/stress protocol may become helpful to study endothelial function in normal physiology and in physiopathology.

Learning-based automatic detection of severe coronary stenoses in CT angiographies

NASA Astrophysics Data System (ADS)

Melki, Imen; Cardon, Cyril; Gogin, Nicolas; Talbot, Hugues; Najman, Laurent

2014-03-01

3D cardiac computed tomography angiography (CCTA) is becoming a standard routine for non-invasive heart diseases diagnosis. Thanks to its high negative predictive value, CCTA is increasingly used to decide whether or not the patient should be considered for invasive angiography. However, an accurate assessment of cardiac lesions using this modality is still a time consuming task and needs a high degree of clinical expertise. Thus, providing automatic tool to assist clinicians during the diagnosis task is highly desirable. In this work, we propose a fully automatic approach for accurate severe cardiac stenoses detection. Our algorithm uses the Random Forest classi cation to detect stenotic areas. First, the classi er is trained on 18 CT cardiac exams with CTA reference standard. Then, then classi cation result is used to detect severe stenoses (with a narrowing degree higher than 50%) in a 30 cardiac CT exam database. Features that best captures the di erent stenoses con guration are extracted along the vessel centerlines at di erent scales. To ensure the accuracy against the vessel direction and scale changes, we extract features inside cylindrical patterns with variable directions and radii. Thus, we make sure that the ROIs contains only the vessel walls. The algorithm is evaluated using the Rotterdam Coronary Artery Stenoses Detection and Quantication Evaluation Framework. The evaluation is performed using reference standard quanti cations obtained from quantitative coronary angiography (QCA) and consensus reading of CTA. The obtained results show that we can reliably detect severe stenosis with a sensitivity of 64%.

Thrombolysis in myocardial infarction frame count in coronary arteries without visible atherosclerosis in coronary angiography of patients with stable coronary artery disease.

PubMed

Tacoy, Gulten A; Yazici, Guliz E; Kocaman, Sinan A; Ozdemir, Murat H

2009-06-01

To investigate the thrombolysis in myocardial infarction (TIMI) frame count (TFC) in the coronary arteries without visible atherosclerosis in coronary angiography of patients with stable coronary artery disease (CAD). Eighty-three patients (mean age 58+/-10, 31 [37%] males), who underwent coronary angiographic evaluation for stable angina in Gazi University, Ankara, Turkey, Cardiology clinic between 2006-2007 were enrolled. Forty patients with normal coronary arteries were defined as group I. Group II consisted of 43 patients, who have one normal coronary artery in the setting of stable CAD defined as stenoses 50% or greater in at least one major coronary artery. Coronary blood flow and microvascular perfusion was evaluated by TFC. In group II, the TFC of left anterior descending artery (LAD) in 15 patients, TFC of circumflex artery (CX) in 18 patient, and TFC of right coronary artery (RCA) in 10 patients were evaluated. In group II, the TFC of LAD (37+/-12 versus 29+/-12, p=0.015) and CX (22+/-8 versus 18+/-9, p=0.035) were significantly higher than those in group I. The TFC of RCA was similar between groups (17+/-9 versus 17+/-8, p=0.990). After the adjustment of the risk factors by multivariate regression analyses, the association between TFC and clinical characteristic was statistically non-significant. The TFC decreased in angiographically normal LAD and CX arteries in the setting of stable angina pectoris. The important predictor was CAD alone, irrespective of the clinical parameters.

Leptin receptors are expressed in coronary arteries, and hyperleptinemia causes significant coronary endothelial dysfunction.

PubMed

Knudson, Jarrod D; Dincer, U Deniz; Zhang, Cuihua; Swafford, Albert N; Koshida, Ryoji; Picchi, Andrea; Focardi, Marta; Dick, Gregory M; Tune, Johnathan D

2005-07-01

Obesity is associated with marked increases in plasma leptin concentration, and hyperleptinemia is an independent risk factor for coronary artery disease. As a result, the purpose of this investigation was to test the following hypotheses: 1) leptin receptors are expressed in coronary endothelial cells; and 2) hyperleptinemia induces coronary endothelial dysfunction. RT-PCR analysis revealed that the leptin receptor gene is expressed in canine coronary arteries and human coronary endothelium. Furthermore, immunocytochemistry demonstrated that the long-form leptin receptor protein (ObRb) is present in human coronary endothelium. The functional effects of leptin were determined using pressurized coronary arterioles (<130 microm) isolated from Wistar rats, Zucker rats, and mongrel dogs. Leptin induced pharmacological vasodilation that was abolished by denudation and the nitric oxide synthase inhibitor N(omega)-nitro-l-arginine methyl ester and was absent in obese Zucker rats. Intracoronary leptin dose-response experiments were conducted in anesthetized dogs. Normal and obese concentrations of leptin (0.1-3.0 microg/min ic) did not significantly change coronary blood flow or myocardial oxygen consumption; however, obese concentrations of leptin significantly attenuated the dilation to graded intracoronary doses of acetylcholine (0.3-30.0 microg/min). Additional experiments were performed in canine coronary rings, and relaxation to acetylcholine (6.25 nmol/l-6.25 micromol/l) was significantly attenuated by obese concentrations of leptin (625 pmol/l) but not by physiological concentrations of leptin (250 pmol/l). The major findings of this investigation were as follows: 1) the ObRb is present in coronary arteries and coupled to pharmacological, nitric oxide-dependent vasodilation; and 2) hyperleptinemia produces significant coronary endothelial dysfunction.

Acute heart failure with and without concomitant acute coronary syndromes: patient characteristics, management, and survival.

PubMed

Tarvasmäki, Tuukka; Harjola, Veli-Pekka; Nieminen, Markku S; Siirilä-Waris, Krista; Tolonen, Jukka; Tolppanen, Heli; Lassus, Johan

2014-10-01

Acute coronary syndromes (ACS) may precipitate up to a third of acute heart failure (AHF) cases. We assessed the characteristics, initial management, and survival of AHF patients with (ACS-AHF) and without (nACS-AHF) concomitant ACS. Data from 620 AHF patients were analyzed in a prospective multicenter study. The ACS-AHF patients (32%) more often presented with de novo AHF (61% vs. 43%; P < .001). Although no differences existed between the 2 groups in mean blood pressure, heart rate, or routine biochemistry on admission, cardiogenic shock and pulmonary edema were more common manifestations in ACS-AHF (P < .01 for both). Use of intravenous nitrates, furosemide, opioids, inotropes, and vasopressors, as well as noninvasive ventilation and invasive coronary procedures (angiography, percutaneous coronary intervention, coronary artery bypass graft surgery), were more frequent in ACS-AHF (P < .001 for all). Although 30-day mortality was significantly higher for ACS-AHF (13% vs. 8%; P = .03), survival in the 2 groups at 5 years was similar. Overall, ACS was an independent predictor of 30-day mortality (adjusted odds ratio 2.0, 95% confidence interval 1.07-3.79; P = .03). Whereas medical history and the manifestation and initial treatment of AHF between ACS-AHF and nACS-AHF patients differ, long-term survival is similar. ACS is, however, independently associated with increased short-term mortality. Copyright © 2014 Elsevier Inc. All rights reserved.

[Development of an automated processing method to detect coronary motion for coronary magnetic resonance angiography].

PubMed

Asou, Hiroya; Imada, N; Sato, T

2010-06-20

On coronary MR angiography (CMRA), cardiac motions worsen the image quality. To improve the image quality, detection of cardiac especially for individual coronary motion is very important. Usually, scan delay and duration were determined manually by the operator. We developed a new evaluation method to calculate static time of individual coronary artery. At first, coronary cine MRI was taken at the level of about 3 cm below the aortic valve (80 images/R-R). Chronological change of the signals were evaluated with Fourier transformation of each pixel of the images were done. Noise reduction with subtraction process and extraction process were done. To extract higher motion such as coronary arteries, morphological filter process and labeling process were added. Using these imaging processes, individual coronary motion was extracted and individual coronary static time was calculated automatically. We compared the images with ordinary manual method and new automated method in 10 healthy volunteers. Coronary static times were calculated with our method. Calculated coronary static time was shorter than that of ordinary manual method. And scan time became about 10% longer than that of ordinary method. Image qualities were improved in our method. Our automated detection method for coronary static time with chronological Fourier transformation has a potential to improve the image quality of CMRA and easy processing.

Diagnostic Accuracy of Coronary Computed Tomography Before Aortic Valve Replacement: Systematic Review and Meta-Analysis.

PubMed

Chaikriangkrai, Kongkiat; Jhun, Hye Yeon; Shantha, Ghanshyam Palamaner Subash; Abdulhak, Aref Bin; Tandon, Rudhir; Alqasrawi, Musab; Klappa, Anthony; Pancholy, Samir; Deshmukh, Abhishek; Bhama, Jay; Sigurdsson, Gardar

2018-07-01

In aortic stenosis patients referred for surgical and transcatheter aortic valve replacement (AVR), the evidence of diagnostic accuracy of coronary computed tomography angiography (CCTA) has been limited. The objective of this study was to investigate the diagnostic accuracy of CCTA for significant coronary artery disease (CAD) in patients referred for AVR using invasive coronary angiography (ICA) as the gold standard. We searched databases for all diagnostic studies of CCTA in patients referred for AVR, which reported diagnostic testing characteristics on patient-based analysis required to pool summary sensitivity, specificity, positive-likelihood ratio, and negative-likelihood ratio. Significant CAD in both CCTA and ICA was defined by >50% stenosis in any coronary artery, coronary stent, or bypass graft. Thirteen studies evaluated 1498 patients (mean age, 74 y; 47% men; 76% transcatheter AVR). The pooled prevalence of significant stenosis determined by ICA was 43%. Hierarchical summary receiver-operating characteristic analysis demonstrated a summary area under curve of 0.96. The pooled sensitivity, specificity, and positive-likelihood and negative-likelihood ratios of CCTA in identifying significant stenosis determined by ICA were 95%, 79%, 4.48, and 0.06, respectively. In subgroup analysis, the diagnostic profiles of CCTA were comparable between surgical and transcatheter AVR. Despite the higher prevalence of significant CAD in patients with aortic stenosis than with other valvular heart diseases, our meta-analysis has shown that CCTA has a suitable diagnostic accuracy profile as a gatekeeper test for ICA. Our study illustrates a need for further study of the potential role of CCTA in preoperative planning for AVR.

Association of Medical Liability Reform With Clinician Approach to Coronary Artery Disease Management.

PubMed

Farmer, Steven A; Moghtaderi, Ali; Schilsky, Samantha; Magid, David; Sage, William; Allen, Nori; Masoudi, Frederick A; Dor, Avi; Black, Bernard

2018-06-06

Physicians often report practicing defensive medicine to reduce malpractice risk, including performing expensive but marginally beneficial tests and procedures. Although there is little evidence that malpractice reform affects overall health care spending, it may influence physician behavior for specific conditions involving clinical uncertainty. To examine whether reducing malpractice risk is associated with clinical decisions involving coronary artery disease testing and treatment. Difference-in-differences design, comparing physician-specific changes in coronary artery disease testing and treatment in 9 new-cap states that adopted damage caps between 2003 and 2005 with 20 states without caps. We used the 5% national Medicare fee-for-service random sample between 1999 and 2013. Physicians (n = 75 801; 36 647 in new-cap states) who ordered or performed 2 or more coronary angiographies. Data were analyzed from June 2015 to January 2018. Changes in ischemic evaluation rates for possible coronary artery disease, type of initial evaluation (stress testing or coronary angiography), progression from stress test to angiography, and progression from ischemic evaluation to revascularization (percutaneous coronary intervention or coronary artery bypass grafting). We studied 36 647 physicians in new-cap states and 39 154 physicians in no-cap states. New-cap states had younger populations, more minorities, lower per-capita incomes, fewer physicians per capita, and lower managed care penetration. Following cap adoption, new-cap physicians reduced invasive testing (angiography) as a first diagnostic test compared with control physicians (relative change, -24%; 95% CI, -40% to -7%; P = .005) with an offsetting increase in noninvasive stress testing (7.8%; 95% CI, -3.6% to 19.3%; P = .17), and referred fewer patients for angiography following stress testing (-21%; 95% CI, -40% to -2%; P = .03). New-cap physicians also reduced revascularization rates after

A Randomized-Controlled Trial Examining the Effects of Reflexology on Anxiety of Patients Undergoing Coronary Angiography

PubMed Central

Molavi Vardanjani, Mehdi; Masoudi Alavi, Negin; Razavi, Narges Sadat; Aghajani, Mohammad; Azizi-Fini, Esmail; Vaghefi, Seied Morteza

2013-01-01

Background: The anxiety reduction before coronary angiography has clinical advantages and is one of the objectives of nursing. Reflexology is a non-invasive method that has been used in several clinical situations. Applying reflexology might have effect on the reduction of anxiety before coronary angiography. Objectives: The aim of this randomized clinical trial was to investigate the effect of reflexology on anxiety among patients undergoing coronary angiography. Patients and Methods: This trial was conducted in Shahid Beheshti Hospital, in Kashan, Iran. One hundred male patients who were undergoing coronary angiography were randomly enrolled into intervention and placebo groups. The intervention protocol was included 30 minutes of general foot massage and the stimulation of three reflex points including solar plexus, pituitary gland, and heart. The placebo group only received the general foot massage. Spielbergers state trait anxiety inventory was used to assess the anxiety experienced by patients. Data was analyzed using Man-Witney, Wilcoxon and Chi-square tests. The stepwise multiple regressions used to analyze the variables that are involved in anxiety reduction. Results: The mean range of anxiety decreased from 53.24 to 45.24 in reflexology group which represented 8 score reduction (P = 0.0001). The reduction in anxiety was 5.9 score in placebo group which was also significant (P = 0.0001). The anxiety reduction was significantly higher in reflexology group (P = 0.014). The stepwise multiple regression analysis showed that doing reflexology can explain the 7.5% of anxiety reduction which made a significant model. Conclusions: Reflexology can decrease the anxiety level before coronary angiography. Therefore, reflexology before coronary angiography is recommended. PMID:25414869

Treatment-associated musculoskeletal and vasomotor symptoms and relapse-free survival in the NCIC CTG MA.27 adjuvant breast cancer aromatase inhibitor trial.

PubMed

Stearns, Vered; Chapman, Judith-Anne W; Ma, Cynthia X; Ellis, Matthew J; Ingle, James N; Pritchard, Kathleen I; Budd, G Thomas; Rabaglio, Manuela; Sledge, George W; Le Maitre, Aurélie; Kundapur, Jessica; Liedke, Pedro E R; Shepherd, Lois E; Goss, Paul E

2015-01-20

Treatment-emergent symptoms with adjuvant tamoxifen and aromatase inhibitors (AIs) have been associated with superior recurrence-free survival (RFS). We hypothesized that MA.27 anastrozole- or exemestane-treated patients with new or worsening vasomotor and/or joint symptoms would have improved RFS. MA.27 randomly assigned 7,576 postmenopausal women with breast cancer to 5 years of anastrozole or exemestane. Patient-reported symptoms were collected using the Common Terminology Criteria for Adverse Events version 3.0 at protocol-specified baseline and 6- and 12-month clinical visits. Symptoms were considered present with either vasomotor and/or joint complaints. Associations between symptoms and baseline patient characteristics were examined with χ(2) and Fisher's exact tests. Subsequent effects of new or worsening symptoms on RFS were examined with landmark analyses and stratified univariable and multivariable Cox models. We examined the effects of 3-month symptoms arising from unplanned clinic visits as a result of severe toxicity. Patients were assessable if eligible for the MA.27 trial, received some trial therapy, and had no disease recurrence at the end of a symptom assessment period; 96% of patients (n = 7,306 patients) were included at 6 months, and 96% (n = 7,246) were included at 12 months. Thirty-four percent of patients had baseline symptoms. For patients without baseline symptoms, 25% and 52% had new symptoms by 6 and 12 months, respectively. Neither treatment-emergent nor baseline symptoms significantly impacted RFS (P > .10) in patients with or without baseline symptoms. In MA.27, anastrozole or exemestane treatment-emergent symptoms were not associated with improved RFS. Women should be supported through treatment and encouraged to remain on their AI regardless of their symptoms. © 2014 by American Society of Clinical Oncology.

Coronary artery fistula

MedlinePlus

Congenital heart defect - coronary artery fistula; Birth defect heart - coronary artery fistula ... attaches to one of the chambers of the heart (the atrium or ventricle) or another blood vessel ( ...

Vasomotor tone does not affect perfusion heterogeneity and gas exchange in normal primate lungs during normoxia

NASA Technical Reports Server (NTRS)

Glenny, R. W.; Robertson, H. T.; Hlastala, M. P.

2000-01-01

To determine whether vasoregulation is an important cause of pulmonary perfusion heterogeneity, we measured regional blood flow and gas exchange before and after giving prostacyclin (PGI(2)) to baboons. Four animals were anesthetized with ketamine and mechanically ventilated. Fluorescent microspheres were used to mark regional perfusion before and after PGI(2) infusion. The lungs were subsequently excised, dried inflated, and diced into approximately 2-cm(3) pieces (n = 1,208-1,629 per animal) with the spatial coordinates recorded for each piece. Blood flow to each piece was determined for each condition from the fluorescent signals. Blood flow heterogeneity did not change with PGI(2) infusion. Two other measures of spatial blood flow distribution, the fractal dimension and the spatial correlation, did not change with PGI(2) infusion. Alveolar-arterial O(2) differences did not change with PGI(2) infusion. We conclude that, in normal primate lungs during normoxia, vasomotor tone is not a significant cause of perfusion heterogeneity. Despite the heterogeneous distribution of blood flow, active regulation of regional perfusion is not required for efficient gas exchange.

Perspective on CFD studies of coronary artery disease lesions and hemodynamics: a review.

PubMed

Zhang, Jun-Mei; Zhong, Liang; Su, Boyang; Wan, Min; Yap, Jinq Shya; Tham, Jasmine P L; Chua, Leok Poh; Ghista, Dhanjoo N; Tan, Ru San

2014-06-01

Coronary artery disease (CAD) is the most common cardiovascular disease. Early diagnosis of CAD's physiological significance is of utmost importance for guiding individualized risk-tailored treatment strategies. In this paper, we first review the state-of-the-art clinical diagnostic indices to quantify the severity of CAD and the associated invasive and noninvasive imaging technologies in order to quantify the anatomical parameters of diameter stenosis, area stenosis, and hemodynamic indices of coronary flow reserve and fractional flow reserve. With the development of computational technologies and CFD methods, tremendous progress has been made in applying image-based CFD simulation techniques to elucidate the effects of hemodynamics in vascular pathophysiology toward the initialization and progression of CAD. So then, we review the advancements of CFD technologies in patient-specific modeling, involving the development of geometry reconstruction, boundary conditions, and fluid-structure interaction. Next, we review the applications of CFD to stenotic sites, in order to compute their hemodynamic parameters and study the relationship between the hemodynamic conditions and the clinical indices, to thereby assess the amount of viable myocardium and candidacy for percutaneous coronary intervention. Finally, we review the strengths and limitations of current researches of applying CFD to CAD studies. Copyright © 2014 John Wiley & Sons, Ltd.

Coronary heart disease

MedlinePlus

Heart disease, Coronary heart disease, Coronary artery disease; Arteriosclerotic heart disease; CHD; CAD ... buildup of plaque in the arteries to your heart. This may also be called hardening of the ...

Coronary artery anomalies in Turner Syndrome.

PubMed

Viuff, Mette H; Trolle, Christian; Wen, Jan; Jensen, Jesper M; Nørgaard, Bjarne L; Gutmark, Ephraim J; Gutmark-Little, Iris; Mortensen, Kristian H; Gravholt, Claus Højbjerg; Andersen, Niels H

Congenital heart disease, primarily involving the left-sided structures, is often seen in patients with Turner Syndrome. Moreover, a few case reports have indicated that coronary anomalies may be more prevalent in Turner Syndrome than in the normal population. We therefore set out to systematically investigate coronary arterial anatomy by computed tomographic coronary angiography (coronary CTA) in Turner Syndrome patients. Fifty consecutive women with Turner Syndrome (mean age 47 years [17-71]) underwent coronary CTA. Patients were compared with 25 gender-matched controls. Coronary anomaly was more frequent in patients with Turner Syndrome than in healthy controls [20% vs. 4% (p = 0.043)]. Nine out of ten abnormal cases had an anomalous left coronary artery anatomy (absent left main trunk, n = 7; circumflex artery originating from the right aortic sinus, n = 2). One case had a tubular origin of the right coronary artery above the aortic sinus. There was no correlation between the presence of coronary arterial anomalies and karyotype, bicuspid aortic valve, or other congenital heart defects. Coronary anomalies are highly prevalent in Turner Syndrome. The left coronary artery is predominantly affected, with an absent left main coronary artery being the most common anomaly. No hemodynamically relevant coronary anomalies were found. Copyright © 2016 Society of Cardiovascular Computed Tomography. All rights reserved.

Cyclooxygenase inhibition improves endothelial vasomotor dysfunction of visceral adipose arterioles in human obesity

PubMed Central

Farb, Melissa G.; Tiwari, Stephanie; Karki, Shakun; Ngo, Doan TM; Carmine, Brian; Hess, Donald T.; Zuriaga, Maria A.; Walsh, Kenneth; Fetterman, Jessica L.; Hamburg, Naomi M.; Vita, Joseph A.; Apovian, Caroline M.; Gokce, Noyan

2013-01-01

Objective The purpose of this study was to determine whether cyclooxygenase inhibition improves vascular dysfunction of adipose microvessels from obese humans. Design and Methods In 20 obese subjects (age 37±12 yrs, BMI 47±8 kg/m2) we collected subcutaneous and visceral fat during bariatric surgery and characterized adipose depot-specific gene expression, endothelial cell phenotype, and microvascular function. Vasomotor function was assessed in response to endothelium-dependent agonists using videomicroscopy of small arterioles from fat. Results Arterioles from visceral fat exhibited impaired endothelium-dependent, acetylcholine-mediated vasodilation, compared to the subcutaneous depot (p<0.001). Expression of mRNA transcripts relevant to the cyclooxygenase pathway were upregulated in visceral compared to subcutaneous fat. Pharmacological inhibition of cyclooxygenase with indomethacin improved endothelium-dependent vasodilator function of arterioles from visceral fat by 2-fold (p=0.01), whereas indomethacin had no effect in the subcutaneous depot. Indomethacin increased activation via serine-1177 phosphorylation of endothelial nitric oxide synthase in response to acetylcholine in endothelial cells from visceral fat. Inhibition of endothelial nitric oxide synthase with Nω-nitro-L-arginine methyl ester abrogated the effects of cyclooxygenase-inhibition suggesting that vascular actions of indomethacin were related to increased nitric oxide bioavailability. Conclusions Our findings suggest that cyclooxygenase-mediated vasoconstrictor prostanoids partly contribute to endothelial dysfunction of visceral adipose arterioles in human obesity. PMID:23640904

Coronary Physiology During Exercise and Vasodilation in the Healthy Heart and in Severe Aortic Stenosis.

PubMed

Lumley, Matthew; Williams, Rupert; Asrress, Kaleab N; Arri, Satpal; Briceno, Natalia; Ellis, Howard; Rajani, Ronak; Siebes, Maria; Piek, Jan J; Clapp, Brian; Redwood, Simon R; Marber, Michael S; Chambers, John B; Perera, Divaka

2016-08-16

Severe aortic stenosis (AS) can manifest as exertional angina even in the presence of unobstructed coronary arteries. The authors describe coronary physiological changes during exercise and hyperemia in the healthy heart and in patients with severe AS. Simultaneous intracoronary pressure and flow velocity recordings were made in unobstructed coronary arteries of 22 patients with severe AS (mean effective orifice area 0.7 cm(2)) and 38 controls, at rest, during supine bicycle exercise, and during hyperemia. Stress echocardiography was performed to estimate myocardial work. Wave intensity analysis was used to quantify waves that accelerate and decelerate coronary blood flow (CBF). Despite a greater myocardial workload in AS patients compared with controls at rest (12,721 vs. 9,707 mm Hg/min(-1); p = 0.003) and during exercise (27,467 vs. 20,841 mm Hg/min(-1); p = 0.02), CBF was similar in both groups. Hyperemic CBF was less in AS compared with controls (2,170 vs. 2,716 cm/min(-1); p = 0.05). Diastolic time fraction was greater in AS compared with controls, but minimum microvascular resistance was similar. With exercise and hyperemia, efficiency of perfusion improved in the healthy heart, demonstrated by an increase in the relative contribution of accelerating waves. By contrast, in AS, perfusion efficiency decreased due to augmentation of early systolic deceleration and an attenuated rise in systolic acceleration waves. Invasive coronary physiological evaluation can be safely performed during exercise and hyperemia in patients with severe aortic stenosis. Ischemia in AS is not related to microvascular disease; rather, it is driven by abnormal cardiac-coronary coupling. Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Vasomotor symptoms: viewpoint from the Indian subcontinent and management of a common menopausal problem.

PubMed

Shah, Duru; Agrawal, Sangeeta

2010-09-01

Vasomotor symptoms (VMS) are recognized to adversely affect the quality of life. The prevalence and the magnitude of VMS may vary across populations. Although a natural regression of VMS may be expected over a period of time, it remains the most common of symptoms for which women seek help. Menopausal hormone therapy (MHT) is currently the only treatment approved by the Food and Drug Administration that has shown uniform benefit in the management of VMS. In clinical situations when estrogen is or may be contraindicated, a finite number of alternative options, including use of neuroactive agents (SSRIs, SSNRs, and gabapentin), lifestyle changes, and nonprescription remedies such as phytoestrogens and black cohosh have been shown to provide relief, albeit with mixed results and questionable safety. Existing data identify an ethnic variation in the degree and frequency of VMS of aging; in this latter context, the Asian woman's perspective is dominantly conveyed from the perspective of Chinese and Japanese ethnicities, whereas data regarding the magnitude of burden of VMS in the postmenopausal women from other Asian ethnicities and races are sparse. This article reviews the symptoms and relates that VMS are of significant concern for the aging Asian women. © Thieme Medical Publishers.

[Angina pectoris and coronary insufficiency with a normal coronary angiogram: pathophysiological principles, diagnosis and therapeutic consequences].

PubMed

Strauer, B E

1988-01-01

The clinical syndrome "coronary insufficience at normal coronary arteriogram" is found in approximately 10-20% of patients with exercise-induced coronary insufficience. In most of these cases disturbances of coronary microcirculation are present. They can appear in vascular diseases (arterial hypertension, systemic immunopathies, immune complex vasculitis, etc.), in rheological diseases (paraproteinemia, hyperlipoproteinemia, polyglobulia, etc.), and in disturbances of transport and diffusion of oxygen (carbon monoxide intoxication, methemoglobinemia, hyperlipoproteinemia). The clinical diagnosis is based on usual diagnostic programs (electrocardiogram, exercise electrocardiogram, responsiveness to nitroglycerin, etc.), as well as on newer, functionally orientated diagnostic procedures (determinations of coronary blood flow and of coronary vascular reserve, production of lactate, serological findings, histology and immune histology of peripheral arteries, measurements of viscosities in both plasma and blood, etc.). Many clinically relevant disturbances in coronary microcirculation can thus be detected and treated on a rational basis by the management of the internal main disease, that is, by the treatment of the vascular, rheological, and metabolic disorders. Persistent angina pectoris in the presence of normal coronary arteriogram represents no termination of coronary diagnostics, but moreover implies the clinical task for using diagnostic possibilities to enable functional and therapeutical assessment of coronary microcirculation.

Current status of hybrid coronary revascularization.

PubMed

Jaik, Nikhil P; Umakanthan, Ramanan; Leacche, Marzia; Solenkova, Natalia; Balaguer, Jorge M; Hoff, Steven J; Ball, Stephen K; Zhao, David X; Byrne, John G

2011-10-01

Hybrid coronary revascularization combines coronary artery bypass surgery with percutaneous coronary intervention techniques to treat coronary artery disease. The potential benefits of such a technique are to offer the patients the best available treatments for coronary artery disease while minimizing the risks of the surgery. Hybrid coronary revascularization has resulted in the establishment of new 'hybrid operating suites', which incorporate and integrate the capabilities of a cardiac surgery operating room with that of an interventional cardiology laboratory. Hybrid coronary revascularization has greatly augmented teamwork and cooperation between both fields and has demonstrated encouraging as well as good initial outcomes.

Single left coronary artery with separate origins of proximal and distal right coronary arteries from left anterior descending and circumflex arteries--a previously undescribed coronary circulation.

PubMed

Kaul, Pankaj; Javangula, Kalyana

2007-04-20

A single left coronary artery with right coronary artery arising from either left main stem (LMS) or left anterior descending artery (LAD) or circumflex artery (Cx) is an extremely rare coronary anomaly. This is the first report of separate origins of proximal and distal RCA from LAD and circumflex arteries respectively in a patient with a single left coronary artery. This 57 year old patient presented with unstable angina and severe stenotic disease of LAD and Cx arteries and underwent urgent successful quadruple coronary artery bypass grafting. The anomalies of right coronary artery in terms of their origin, number and distribution are reviewed.

The development of a non-invasive behavioral model of thermal heat stress in laboratory mice (Mus musculus).

PubMed

Mufford, J T; Paetkau, M J; Flood, N J; Regev-Shoshani, G; Miller, C C; Church, J S

2016-08-01

Many behavioral and physiological studies of laboratory mice employ invasive methods such as radio telemetry to measure key aspects of behavior and physiology. Radio telemetry requires surgical implants, which may impact mouse health and behavior, and thus reduce the reliability of the data collected. We developed a method to measure key aspects of thermoregulatory behavior without compromising animal welfare. We examined the thermoregulatory response to heat stress in a custom-built arena that permitted the use of simultaneous and continuous infrared thermography (IRT) and video capture. This allowed us to measure changes in surface body temperature and determine total distance traveled using EthoVision XT animal tracking software. Locomotor activity and surface body temperature differed between heat-stressed mice and mice kept within their thermal comfort zone. The former had an increase in surface body temperature and a decline in locomotor activity, whereas the latter had a stable surface body temperature and showed greater activity levels. Surface body temperature and locomotor activity are conventionally quantified by measurements taken at regular intervals, which limit the use and accuracy of the data. We obtained data of high resolution (i.e., recorded continuously) and accuracy that allowed for the examination of key physiological measurements such as energy expenditure and peripheral vasomotor tone. This novel experimental method for studying thermoregulatory behavior in mice using non-invasive tools has advantages over radio-telemetry and represents an improvement in laboratory animal welfare. Copyright © 2015 Elsevier B.V. All rights reserved.

Coronary artery bypass grafting in octogenarians: only when percutaneous coronary intervention is not feasible?

PubMed

Nicolini, Francesco

2015-11-01

The aim of this study was to review recent literature reporting the results of coronary revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients older than 80 years. The review of recent studies on octogenarians demonstrates a surgical CABG advantage in the case of patients with increasing baseline coronary risk, such as severe multivessel disease, chronic total occlusions, and left ventricular dysfunction. PCI seems to be more appropriate for less severe degree and distribution of coronary lesions, and for subgroups of patients with higher surgical risk, such as acute coronary syndromes, reoperations, malignancy, dementia, poor mobility, frailty, and serious comorbidities contraindicating extracorporeal circulation. It is not the case that CABG is indicated only when there are contraindications to PCI. CABG confers more benefit than PCI in patients with increasing baseline cardiac risk, in the absence of serious systemic diseases that can reasonably reduce their life expectancy.CABG and PCI, with proper selection, should be considered complementary rather than competitive procedures in the therapy of octogenarians affected by coronary artery disease.

A Case of Cardiac Cephalalgia Showing Reversible Coronary Vasospasm on Coronary Angiogram

PubMed Central

Yang, YoungSoon; Jin, Dong Gyu; Jang, Il Mi; Jang, YoungHee; Na, Hae Ri; Kim, SanYun

2010-01-01

Background Under certain conditions, exertional headaches may reflect coronary ischemia. Case Report A 44-year-old woman developed intermittent exercise-induced headaches with chest tightness over a period of 10 months. Cardiac catheterization followed by acetylcholine provocation demonstrated a right coronary artery spasm with chest tightness, headache, and ischemic effect of continuous electrocardiography changes. The patient's headache disappeared following intra-arterial nitroglycerine injection. Conclusions A coronary angiogram with provocation study revealed variant angina and cardiac cephalalgia, as per the International Classification of Headache Disorders (code 10.6). We report herein a patient with cardiac cephalalgia that manifested as reversible coronary vasospasm following an acetylcholine provocation test. PMID:20607049

[Endarterectomy of the coronary arteries].

PubMed

Fischer, V; Simkovic, I; Holoman, M; Verchvodko, P; Janotík, P; Galbánek, J; Hulman, M; Kostelnicák, J; Jurco, R; Slezák, J

1992-02-01

The authors analyze 50 patients with endarterectomy of the coronary arteries during the periods of 1972-1974 and 1988-1990. The results of endarterectomy of the right and left coronary artery provide evidence of its justification in indicated cases whereby contrary to some departments the results of endarterectomy of the left coronary artery are comparable with endarterectomy of the right coronary artery.

64-Slice Computed Tomographic Angiography for the Diagnosis of Intermediate Risk Coronary Artery Disease

PubMed Central

2010-01-01

Executive Summary In July 2009, the Medical Advisory Secretariat (MAS) began work on Non-Invasive Cardiac Imaging Technologies for the Diagnosis of Coronary Artery Disease (CAD), an evidence-based review of the literature surrounding different cardiac imaging modalities to ensure that appropriate technologies are accessed by patients suspected of having CAD. This project came about when the Health Services Branch at the Ministry of Health and Long-Term Care asked MAS to provide an evidentiary platform on effectiveness and cost-effectiveness of non-invasive cardiac imaging modalities. After an initial review of the strategy and consultation with experts, MAS identified five key non-invasive cardiac imaging technologies for the diagnosis of CAD. Evidence-based analyses have been prepared for each of these five imaging modalities: cardiac magnetic resonance imaging, single photon emission computed tomography, 64-slice computed tomographic angiography, stress echocardiography, and stress echocardiography with contrast. For each technology, an economic analysis was also completed (where appropriate). A summary decision analytic model was then developed to encapsulate the data from each of these reports (available on the OHTAC and MAS website). The Non-Invasive Cardiac Imaging Technologies for the Diagnosis of Coronary Artery Disease series is made up of the following reports, which can be publicly accessed at the MAS website at: www.health.gov.on.ca/mas or at www.health.gov.on.ca/english/providers/program/mas/mas_about.html Single Photon Emission Computed Tomography for the Diagnosis of Coronary Artery Disease: An Evidence-Based Analysis Stress Echocardiography for the Diagnosis of Coronary Artery Disease: An Evidence-Based Analysis Stress Echocardiography with Contrast for the Diagnosis of Coronary Artery Disease: An Evidence-Based Analysis 64-Slice Computed Tomographic Angiography for the Diagnosis of Coronary Artery Disease: An Evidence-Based Analysis Cardiac

Regression of left ventricular hypertrophy provides an additive physiological benefit following treatment of aortic stenosis: insights from serial coronary wave-intensity analysis.

PubMed

Broyd, Christopher J; Rigo, Fausto; Nijjer, Sukhjinder; Sen, Sayan; Petraco, Ricardo; Al-Lamee, Rasha; Foin, Nicolas; Chukwuemeka, Andrew; Anderson, Jon; Parker, Jessica; Malik, Iqbal S; Mikhail, Ghada W; Francis, Darrel P; Parker, Kim; Hughes, Alun D; Mayet, Jamil; Davies, Justin E

2018-06-23

Severe aortic stenosis frequently involves the development of left ventricular hypertrophy (LVH) creating a dichotomous hemodynamic state within the coronary circulation. Whilst the increased force of ventricular contraction enhances its resultant relaxation and thus increases the distal diastolic coronary 'suction' force, the presence of LVH has a potentially opposing effect on ventricular-coronary interplay. The aim of this study was to use non-invasive coronary wave-intensity analysis (WIA) to separate and measure the sequential effects of outflow-tract obstruction relief and then left ventricular hypertrophy (LVH) regression following intervention for aortic stenosis. 15 patients with unobstructed coronary arteries undergoing aortic valve intervention (11 SAVR, 4 TAVI) were successfully assessed before and after intervention, and at 6- and 12-months post-procedure. Coronary WIA was constructed from simultaneously acquired coronary flow from transthoracic echo and pressure from an oscillometric brachial-cuff system. Immediately following intervention, a decline in the BDW was noted (9.7±5.7 vs 5.1±3.6 x10 3 Wm -2 s -1 , p<0.01). Over 12 months, LV mass-index fell from 114±19 to 82±17 kg/m 2 . Accompanying this, the BDW fraction increased to 32.8±7.2% (p=0.01 vs post-procedure) and to 34.7±6.7% at 12 months (p<0.001 vs post-procedure). In aortic stenosis, both the outflow-tract gradient and the presence of LVH impact significantly on coronary haemodynamics that cannot be appreciated by examining resting coronary flow rates alone. An immediate change in coronary wave-intensity occurs following intervention with further effects appreciable with hypertrophy regression. The improvement in prognosis with treatment is likely to be attributable to both features. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Coronary artery dimensions in normal Indians.

PubMed

Raut, Barendra Kumar; Patil, Vijaysinh Namdeo; Cherian, George

Diameter of coronary artery is an important predictor of outcome after percutaneous coronary interventions and coronary artery bypass graft surgery. There is very limited data available about coronary artery dimensions in an Indian population. To study the normal dimensions of the coronary artery segments in Indians without coronary artery disease by using quantitative coronary angiography and also to compare the dimensions in Indians with Western. 229 patients who have undergone coronary angiography with entirely normal coronary angiogram were included in our study. This study showed the diameter of vessels in males and females when taken together the left main was larger in size followed by proximal LAD, proximal RCA & proximal LCX respectively (4.08±0.44mm, 3.27±0.23mm, 3.20±0.37mm, 2.97±0.37mm).When the vessel diameter was indexed to body surface area there was no statistical difference between male and female (p value>0.05). The computed value of proximal coronary artery diameter unadjusted for individual body surface area, when compared to Caucasians showed that Caucasians have larger coronary artery dimensions than Indians. But when the proximal vessel diameter was indexed to body surface area there was no statistical significant difference between Indians and Caucasians (p value>0.05). We found that coronary artery size when indexed to body surface area is not statistically different in Indian males and females and compared to Caucasians. However with a smaller body habitus Indians have smaller coronary arteries. Copyright © 2017. Published by Elsevier B.V.

Effect of Prior Aspirin Treatment on Patients With Acute Coronary Syndromes: Insights From the PROSPECT Study.

PubMed

Brener, Sorin J; Maehara, Akiko; Mintz, Gary S; Weisz, Giora; de Bruyne, Bernard; Serruys, Patrick W; Stone, Gregg W

2015-12-01

Prior aspirin treatment is considered a risk factor for adverse outcomes in acute coronary syndrome (ACS) patients. The relationships between aspirin pretreatment and findings on quantitative coronary angiography (QCA) and intravascular ultrasound (IVUS), as well as clinical outcomes, are not well understood. In the PROSPECT trial, QCA and triple-vessel IVUS imaging were performed after successful percutaneous coronary intervention (PCI) of the culprit lesion(s) in ACS patients. We compared patients receiving aspirin within 7 days of enrollment to those naive to aspirin. Propensity score matching was performed to adjust for differences in baseline characteristics. Aspirin-pretreated patients (n = 236; 35%) were older and more likely to have known coronary disease than those without pretreatment (P≤.01 for all). Pretreated patients had more untreated non-culprit lesions with angiographic and IVUS characteristics predictive of future events (53.1% vs 38.6%; P<.001). There were no significant differences in overall major adverse cardiac event (MACE) rates at 3 years between the aspirin and no-aspirin groups (23.6% vs 18.8%, respectively; P=.17) in unadjusted or propensity-adjusted analyses. Prior aspirin use was not an independent predictor of MACE at 3 years (hazard ratio, 1.21; 95% confidence interval, 0.73-2.01; P=.45). In the PROSPECT trial, aspirin pretreatment identifies an older population with more advanced coronary disease. Aspirin pretreatment was not an independent predictor of MACE in ACS patients treated with an early invasive strategy. The extent to which aspirin pretreatment is a risk factor for adverse events after PCI in ACS should be revisited.

Relationship of Hypertension to Coronary Atherosclerosis and Cardiac Events in Patients With Coronary Computed Tomographic Angiography.

PubMed

Nakanishi, Rine; Baskaran, Lohendran; Gransar, Heidi; Budoff, Matthew J; Achenbach, Stephan; Al-Mallah, Mouaz; Cademartiri, Filippo; Callister, Tracy Q; Chang, Hyuk-Jae; Chinnaiyan, Kavitha; Chow, Benjamin J W; DeLago, Augustin; Hadamitzky, Martin; Hausleiter, Joerg; Cury, Ricardo; Feuchtner, Gudrun; Kim, Yong-Jin; Leipsic, Jonathon; Kaufmann, Philipp A; Maffei, Erica; Raff, Gilbert; Shaw, Leslee J; Villines, Todd C; Dunning, Allison; Marques, Hugo; Pontone, Gianluca; Andreini, Daniele; Rubinshtein, Ronen; Bax, Jeroen; Jones, Erica; Hindoyan, Niree; Gomez, Millie; Lin, Fay Y; Min, James K; Berman, Daniel S

2017-08-01

Hypertension is an atherosclerosis factor and is associated with cardiovascular risk. We investigated the relationship between hypertension and the presence, extent, and severity of coronary atherosclerosis in coronary computed tomographic angiography and cardiac events risk. Of 17 181 patients enrolled in the CONFIRM registry (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) who underwent ≥64-detector row coronary computed tomographic angiography, we identified 14 803 patients without known coronary artery disease. Of these, 1434 hypertensive patients were matched to 1434 patients without hypertension. Major adverse cardiac events risk of hypertension and non-hypertensive patients was evaluated with Cox proportional hazards models. The prognostic associations between hypertension and no-hypertension with increasing degree of coronary stenosis severity (nonobstructive or obstructive ≥50%) and extent of coronary artery disease (segment involvement score of 1-5, >5) was also assessed. Hypertension patients less commonly had no coronary atherosclerosis and more commonly had nonobstructive and 1-, 2-, and 3-vessel disease than the no-hypertension group. During a mean follow-up of 5.2±1.2 years, 180 patients experienced cardiac events, with 104 (2.0%) occurring in the hypertension group and 76 (1.5%) occurring in the no-hypertension group (hazard ratios, 1.4; 95% confidence intervals, 1.0-1.9). Compared with no-hypertension patients without coronary atherosclerosis, hypertension patients with no coronary atherosclerosis and obstructive coronary disease tended to have higher risk of cardiac events. Similar trends were observed with respect to extent of coronary artery disease. Compared with no-hypertension patients, hypertensive patients have increased presence, extent, and severity of coronary atherosclerosis and tend to have an increase in major adverse cardiac events. © 2017 American Heart Association, Inc.

Local coronary wall eccentricity and endothelial function are closely related in patients with atherosclerotic coronary artery disease.

PubMed

Hays, Allison G; Iantorno, Micaela; Schär, Michael; Mukherjee, Monica; Stuber, Matthias; Gerstenblith, Gary; Weiss, Robert G

2017-07-06

Coronary endothelial function (CEF) in patients with coronary artery disease (CAD) varies among coronary segments in a given patient. Because both coronary vessel wall eccentricity and coronary endothelial dysfunction are predictors of adverse outcomes, we hypothesized that local coronary endothelial dysfunction is associated with local coronary artery eccentricity. We used 3 T coronary CMR to measure CEF as changes in coronary cross-sectional area (CSA) and coronary blood flow (CBF) during isometric handgrip exercise (IHE), a known endothelial-dependent stressor, in 29 patients with known CAD and 16 healthy subjects. Black-blood MRI quantified mean coronary wall thickness (CWT) and coronary eccentricity index (EI) and CEF was determined in the same segments. IHE-induced changes in CSA and CBF in healthy subjects (10.6 ± 6.6% and 38.3 ± 29%, respectively) were greater than in CAD patients 1.3 ± 7.7% and 6.5 ± 19.6%, respectively, p < 0.001 vs. healthy for both measures), as expected. Mean CWT and EI in healthy subjects (1.1 ± 0.3 mm 1.9 ± 0.5, respectively) were less than those in CAD patients (1.6 ± 0.4 mm, p < 0.0001; and 2.6 ± 0.6, p = 0.006 vs. healthy). In CAD patients, we observed a significant inverse relationship between stress-induced %CSA change and both EI (r = -0.60, p = 0.0002), and CWT (r = -0.54, p = 0.001). Coronary EI was independently and significantly related to %CSA change with IHE even after controlling for mean CWT (adjusted r = -0.69, p = 0.0001). For every unit increase in EI, coronary CSA during IHE is expected to change by -6.7 ± 9.4% (95% confidence interval: -10.3 to -3.0, p = 0.001). There is a significant inverse and independent relationship between coronary endothelial macrovascular function and the degree of local coronary wall eccentricity in CAD patients. Thus anatomic and physiologic indicators of high-risk coronary vascular pathology are

Coronary Heart Disease Preoperative Gesture Interactive Diagnostic System Based on Augmented Reality.

PubMed

Zou, Yi-Bo; Chen, Yi-Min; Gao, Ming-Ke; Liu, Quan; Jiang, Si-Yu; Lu, Jia-Hui; Huang, Chen; Li, Ze-Yu; Zhang, Dian-Hua

2017-08-01

Coronary heart disease preoperative diagnosis plays an important role in the treatment of vascular interventional surgery. Actually, most doctors are used to diagnosing the position of the vascular stenosis and then empirically estimating vascular stenosis by selective coronary angiography images instead of using mouse, keyboard and computer during preoperative diagnosis. The invasive diagnostic modality is short of intuitive and natural interaction and the results are not accurate enough. Aiming at above problems, the coronary heart disease preoperative gesture interactive diagnostic system based on Augmented Reality is proposed. The system uses Leap Motion Controller to capture hand gesture video sequences and extract the features which that are the position and orientation vector of the gesture motion trajectory and the change of the hand shape. The training planet is determined by K-means algorithm and then the effect of gesture training is improved by multi-features and multi-observation sequences for gesture training. The reusability of gesture is improved by establishing the state transition model. The algorithm efficiency is improved by gesture prejudgment which is used by threshold discriminating before recognition. The integrity of the trajectory is preserved and the gesture motion space is extended by employing space rotation transformation of gesture manipulation plane. Ultimately, the gesture recognition based on SRT-HMM is realized. The diagnosis and measurement of the vascular stenosis are intuitively and naturally realized by operating and measuring the coronary artery model with augmented reality and gesture interaction techniques. All of the gesture recognition experiments show the distinguish ability and generalization ability of the algorithm and gesture interaction experiments prove the availability and reliability of the system.

Absent right coronary artery: A case of single coronary artery or congenital ostial atresia?

PubMed

Gupta, Mohit D; Girish, M P; Vignesh, Vickram; Narang, Poonam; Trehan, Vijay; Tyagi, Sanjay

2015-12-01

Atresia of the right coronary artery ostium is a rare anatomic variant of the coronary circulation. It is often difficult to differentiate from single coronary artery. Its presence unassociated with any other anomaly has never been described in an adult individual. We report this unusual anomaly and discuss its anatomical and pathophysiological significance and possible ways to differentiate from single coronary artery. Copyright © 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

Off-pump coronary artery bypass grafting. The 1st Medical Faculty of Charles University study.

PubMed

Semrád, M; Bodlák, P; Stríteský, M; Kristof, J; Lindner, J; Urban, T; Vondrácek, V; Vanĕk, I

2002-01-01

To explore the surgical technique, anaesthesiological management, immediate and mid-term results, graft patency and effectiveness of less invasive coronary artery bypass grafting through a median sternotomy. From January 1998 through December 1999, 144 patients had coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) done by one surgeon through a median sternotomy. The cohort of 107 men and 37 women averaged 60.8 years, mean ejection fraction (EF) was 51.8%. An average of 2.7 (range 1 to 5) grafts/patients was achieved. Results are compared with a CPB subgroup of patients operated on through a median sternotomy in the same time (N = 234). In a random subgroup of 100 patients (50 per group) an angiographic control of graft patency was done. A non-CPB group showed less postoperative acute myocardial infarction (0.7% vs. 3.8%, p < 0.05) and atrial fibrillation (14.6% vs. 26%, p < 0.05), lower incidence of renal (2.8% vs. 5.1%, p < 0.05) and respiratory complications (2.0% vs. 3.8%, NS). We observed lower operative mortality (0.7% vs. 3.4%, p < 0.05), as well as the occurrence of low cardiac output syndrome (0.7% vs. 5.6%, p < 0.05) in the off-pump group. The follow-up is 36 +/- 12 months and the number of patients with recurrent angina, late AMI and late death is acceptable. We did not find an inordinate number of vein grafts occlusions (0.7% vs. 1.8%, NS) and stenoses (6.6% vs. 6.7%, NS) at anastomotic sites. None of the arterial grafts in both groups were occluded. There was little known about the efficacy of the less invasive coronary artery bypass grafting at the beginning of our study. Starting with pioneering the operative technique, we have discovered and proposed three types of a heart verticalization and a reusable stabilizing device. We detected lower incidence of postoperative complications and decreased operative mortality in a non-CPB group. Angiographic assessment displayed an excellent run-off in both groups of patients. Off

CT coronary angiography and exercise ECG in a population with chest pain and low-to-intermediate pre-test likelihood of coronary artery disease.

PubMed

Maffei, Erica; Seitun, Sara; Martini, Chiara; Palumbo, Alessandro; Tarantini, Giuseppe; Berti, Elena; Grilli, Roberto; Tedeschi, Carlo; Messalli, Giancarlo; Guaricci, Andrea; Weustink, Annick C; Mollet, Nico Ra; Cademartiri, Filippo

2010-12-01

To evaluate diagnostic accuracy of exercise ECG (ex-ECG) versus 64-slice CT coronary angiography (CT-CA) for the detection of significant coronary artery stenosis in a population with low-to-intermediate pre-test likelihood of coronary artery disease (CAD). Retrospective single centre. Tertiary academic hospital. 177 consecutive patients (88 men, 89 women, mean age 53.5±7.6 years) with chest pain and low-to-intermediate pre-test likelihood of CAD were retrospectively enrolled. All patients underwent ex-ECG, CT-CA and invasive coronary angiography (ICA). A lumen diameter reduction of ≥50% was considered as significant stenosis for CT-CA. Ex-ECG was classified as positive, negative or non-diagnostic. were compared with ICA. Diagnostic accuracy of CT-CA and ex-ECG was calculated using ICA as the reference standard. A parallel comparative analysis using a cut-off value of 70% for significant lumen reduction was also performed too. Results ICA disclosed an absence of significant stenosis (≥50% luminal narrowing) in 85.3% (151/177) patients, single-vessel disease in 9.0% (16/177) patients and multivessel disease in 5.6% (10/177) patients. Prevalence of obstructive disease at ICA was 14.7% (26/177). Sensitivity, specificity, positive and negative predictive values at the patient level were 100.0%, 98.7%, 92.9%, 100%, respectively, for CT-CA and 46.2%, 16.6%, 8.7%, 64.1%, respectively, for ex-ECG. Agreement between CT-CA and ex-ECG was 20.9%. CT-CA performed equally well in men and women, while ex-ECG had a better performance in men. After considering the cut-off value of 70% for significant stenosis, the difference between CT-CA and ex-ECG remained significant (p<0.01), with a low agreement (21.5%). CT-CA provides optimal diagnostic performance in patients with atypical chest pain and low-to-intermediate risk of CAD. Ex-ECG has poor diagnostic accuracy in this population. Concerns are related to risk of radiation dose versus the benefits of correct disease

The time course of brief and prolonged topical 8% capsaicin-induced desensitization in healthy volunteers evaluated by quantitative sensory testing and vasomotor imaging.

PubMed

Lo Vecchio, Silvia; Andersen, Hjalte Holm; Arendt-Nielsen, Lars

2018-05-29

Topically applied high-concentration capsaicin induces reversible dermo-epidermal denervation and depletion of capsaicin-sensitive nociceptors. This causes desensitization of distinct sensory modalities and is used to treat peripheral neuropathic pain and itch. For high-concentration capsaicin, the selectivity of loss of function and functional recovery rates of various afferent fibers subpopulations are unknown. This study used comprehensive quantitative sensory testing and vasomotor imaging to assess effectiveness, duration and sensory selectivity of high-concentration 8% capsaicin-ablation. Skin areas in 14 healthy volunteers were randomized to treatment with 8% capsaicin/vehicle patches for 1 and 24 h and underwent comprehensive sensory and vasomotor testing at 1, 7 and 21 days postpatch removal. Tests consisted of thermal detection and pain thresholds, tactile and vibration detection thresholds, mechanical pain threshold and mechanical pain sensitivity as well as micro-vascular and itch reactivity to histamine provocations. The 24 h capsaicin drastically inhibited warmth detection (P < 0.001), heat pain (P < 0.001) as well as histamine-induced itch (P < 0.05) and neurogenic flare (P < 0.001), but had no impact on tactile sensitivity, cold detection and cold pain. A marginal decrease in mechanical pain sensitivity was observed (P < 0.05). Capsaicin for 1 h had limited and transient sensory effects only affecting warmth and heat sensations. Time-dependent functional recovery was almost complete 21 days after the 24 h capsaicin exposure, while recovery of neurogenic inflammatory responsiveness remained partial. The psychophysically assessed sensory deficiencies induced by the used 8% capsaicin-ablation correspond well with a predominant effect on TRPV1 + -cutaneous fibers. The method is easy to apply, well tolerated, and utilizable for studies on, e.g., interactions between skin barrier, inflammation and capsaicin-sensitive afferents.

Novel Approach for In Vivo Detection of Vulnerable Coronary Plaques using Molecular 3-T CMR Imaging with an Albumin-Binding Probe.

PubMed

Engel, Leif-Christopher; Landmesser, Ulf; Gigengack, Kevin; Wurster, Thomas; Manes, Constantina; Girke, Georg; Jaguszewski, Milosz; Skurk, Carsten; Leistner, David M; Lauten, Alexander; Schuster, Andreas; Hamm, Bernd; Botnar, Rene M; Makowski, Marcus R; Bigalke, Boris

2018-01-12

This study sought to investigate the potential of the noninvasive albumin-binding probe gadofosveset-enhanced cardiac magnetic resonance (GE-CMR) for detection of coronary plaques that can cause acute coronary syndromes (ACS). ACS are frequently caused by rupture or erosion of coronary plaques that initially do not cause hemodynamically significant stenosis and are therefore not detected by invasive x-ray coronary angiography (XCA). A total of 25 patients with ACS or symptoms of stable coronary artery disease underwent GE-CMR, clinically indicated XCA, and optical coherence tomography (OCT) within 24 h. GE-CMR was performed approximately 24 h following a 1-time application of gadofosveset-trisodium. Contrast-to-noise ratio (CNR) was quantified within coronary segments in comparison with blood signal. A total of 207 coronary segments were analyzed on GE-CMR. Segments containing a culprit lesion in ACS patients (n = 11) showed significant higher signal enhancement (CNR) following gadofosveset-trisodium application than segments without culprit lesions (n = 196; 6.1 [3.9 to 16.5] vs. 2.1 [0.5 to 3.5]; p < 0.001). GE-CMR was able to correctly identify culprit coronary lesions in 9 of 11 segments (sensitivity 82%) and correctly excluded culprit coronary lesions in 162 of 195 segments (specificity 83%). Additionally, segmented areas of thin-cap fibroatheroma (n = 22) as seen on OCT demonstrated significantly higher CNR than segments without coronary plaque or segments containing early atherosclerotic lesions (n = 185; 9.2 [3.3 to 13.7] vs. 2.1 [0.5 to 3.4]; p = 0.001). In this study, we demonstrated for the first time the noninvasive detection of culprit coronary lesions and thin-cap fibroatheroma of the coronary arteries in vivo by using GE-CMR. This method may represent a novel approach for noninvasive cardiovascular risk prediction. Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Catheter-induced dissection of the left main coronary artery, the nemesis of an invasive cardiologist A case report and review of the literature.

PubMed

Jain, Deepak; Kurowski, Volkhard; Katus, Hugo A; Richardt, Gert

2002-10-01

An elderly gentleman had a dissection of the left main coronary artery (LMCA) during coronary angiography. There were critical lesions in the left anterior descending (LAD) and left circumflex arteries. Both the LMCA and the LAD lesions were successfully stented in the same sitting. Thereafter the patient remained symptom free and the six-month follow-up angiogram revealed good angioplasty results in both lesions. We report this case for two reasons - first, acute dissection of the LMCA is a rare but devastating complication of selective coronary angiography and the situation becomes graver if the branch vessels have critical stenosis; that this could be managed percutaneously needs to be highlighted, and second, the case offers an opportunity to review literature pertinent to this awesome occurrence in the catheterization laboratory.

Exertion and acute coronary artery injury.

PubMed

Black, A; Black, M M; Gensini, G

1975-12-01

Twelve cases of myocardial infarction as related to strenuous exertion are presented with the pathological findings in several of these cases. Three cases with coronary arteriography are also presented. The pathology of coronary arteriosclerotic plaques and the vulnerability to acute injury is reviewed and discussed. It is concluded that strenuous exertion can cause acute injury to coronary artery plaques due to the unusual stressful whip-like action to which coronary arteries are subject. These injuries may initiate as cracks in the plaques or subintimal hemorrhages and proceed to coronary occlusion and ultimate myocardial infarction. With this concept in mind we use the term of "crack in the plaque" (Black's Crack in the Plaque) to account for the sudden appearance of clinical coronary artery disease appearing during or shortly after exertion, or other stressful situations in patients without previous existing evidence of clinical coronary artery disease. This could also account for exacerbation of symptoms or death occurring after exertion in previously quiescent asymptomatic known coronary artery disease subjects. This concept may explain some of the puzzling features of coronary disease.

Optimization of coronary attenuation in coronary computed tomography angiography using diluted contrast material.

PubMed

Kawaguchi, Naoto; Kurata, Akira; Kido, Teruhito; Nishiyama, Yoshiko; Kido, Tomoyuki; Miyagawa, Masao; Ogimoto, Akiyoshi; Mochizuki, Teruhito

2014-01-01

The purpose of this study was to evaluate a personalized protocol with diluted contrast material (CM) for coronary computed tomography angiography (CTA). One hundred patients with suspected coronary artery disease underwent retrospective electrocardiogram-gated coronary CTA on a 256-slice multidetector-row CT scanner. In the diluted CM protocol (n=50), the optimal scan timing and CM dilution rate were determined by the timing bolus scan, with 20% CM dilution (5ml/s during 10s) being considered suitable to achieve the target arterial attenuation of 350 Hounsfield units (HU). In the body weight (BW)-adjusted protocol (n=50, 222mg iodine/kg), only the optimal scan timing was determined by the timing bolus scan. The injection rate and volume in the timing bolus scan and real scan were identical between the 2 protocols. We compared the means and variations in coronary attenuation between the 2 protocols. Coronary attenuation (mean±SD) in the diluted CM and BW-adjusted protocols was 346.1±23.9 HU and 298.8±45.2 HU, respectively. The diluted CM protocol provided significantly higher coronary attenuation and lower variance than did the BW-adjusted protocol (P<0.05, in each). The diluted CM protocol facilitates more uniform attenuation on coronary CTA in comparison with the BW-adjusted protocol.  

Restenosis of the coronary stenotic lesions treated by holmium:YAG laser coronary angioplasty

NASA Astrophysics Data System (ADS)

Miyazaki, Shunichi; Nonogi, Hiroshi; Goto, Yoichi; Itoh, Akira; Ozono, Keizaburo; Daikoku, Satoshi; Haze, Kazuo

1994-07-01

Clinical efficacy of newly developed Holmium YAG laser coronary angioplasty (HLCA) was assessed for 30 patients with angina. There were 12 near left main trunk (LMT) lesions and 4 aorto- ostial lesions. Adjunctive balloon angioplasty was performed for 25 of 30 lesions. Delivered energy ranged from 1.5 to 2.5 watts/pulse and the total exposure time ranged from 6 to 55 seconds. External diameter of laser catheter was 1.5 mm for 13 lesions, 1.4 mm for 17 lesions, and 1.7 mm for 5 lesions. Laser success, defined as 20% reduction of stenotic ratio, was obtained in 21 of 30 (70%) and overall procedural success rate was 93%. There were 3 cases with acute coronary occlusions relieved by adjunctive balloon angioplasty and one coronary perforation without manifestation of cardiac tamponade. There were no large coronary dissection which involved more than 5 mm of the coronary artery. Follow up coronary angiography after 3 months showed restenosis in 14 of 27 patients (52%). Percent stenosis after lasering (56%) was similar to that at 3 months after (62%). HLCA is acutely effective treatment for lesions near LMT, because of low incidence of large coronary dissection. However, angiographical restenosis rate is high at 3 months after HLCA. This may be attributed to the relatively large residual stenosis after the procedure and vessel injury caused by shock wave.

Availability of highly sensitive troponin assays and acute coronary syndrome care: insights from the SNAPSHOT registry.

PubMed

Cullen, Louise; French, John K; Briffa, Tom G; Redfern, Julie; Hammett, Christopher J K; Brieger, David B; Parsonage, William A; Lefkovits, Jeffrey; Ellis, Chris; Astley, Carolyn; Howell, Tegwen Eleanor; Elliott, John M; Chew, Derek P B

2015-01-19

To examine differences in care and inhospital course of patients with possible acute coronary syndrome (ACS) in Australia and New Zealand based on whether a highly sensitive (hs) troponin assay was used at the hospital to which they presented. A snapshot study of consecutive patients presenting to hospitals in Australia and New Zealand from 14 to 27 May 2012 with possible ACS. Rates of major adverse cardiac events (inhospital death, new or recurrent myocardial infarction, stroke, cardiac arrest or worsening heart failure); association between assay type and outcome (via propensity score matching and a generalised estimating equation [GEE]; averages of the predicted outcomes among patients who were treated with and without the availability of an hs assay (via inverse probability-weighting [IPW] with regression-adjusted estimators). 4371 patients with possible ACS were admitted to 283 hospitals. Over half of the hospitals (156 [55%]) reported using the hs assay and most patients (2624 [60%]) had hs tests (P = 0.004). Use of the hs assay was independent of hospital coronary revascularisation capability. Patients tested with the hs assay had more non-invasive investigations (exercise tests, stress echocardiography, stress nuclear scans, and computed tomography coronary angiography) than those tested with the sensitive assay. However, there were no differences between the groups in rates of angiography or revascularisation. All adjusted analyses showed a consistently lower rate of inhospital events, including recurrent heart failure in patients for whom the hs assay was used (GEE odds ratio, 0.75; 95% CI, 0.60-0.94; P = 0.014); IPW analysis showed a 2.3% absolute reduction in these events with the use of the hs assay (P = 0.018). Use of hs troponin testing of patients hospitalised with possible ACS was associated with an increased rate of non-invasive cardiac investigations and fewer inhospital adverse events.

Noninvasive Imaging in Coronary Artery Disease

PubMed Central

Heo, Ran; Nakazato, Ryo; Kalra, Dan; Min, James K.

2014-01-01

Noninvasive cardiac imaging is widely used to evaluate the presence of coronary artery disease. Recently, with improvements in imaging technology, noninvasive imaging has also been used for evaluation of the presence, severity, and prognosis of coronary artery disease. Coronary CT angiography and MRI of coronary arteries provide an anatomical assessment of coronary stenosis, whereas the hemodynamic significance of a coronary artery stenosis can be assessed by stress myocardial perfusion imaging, such as SPECT/PET and stress MRI. For appropriate use of multiple imaging modalities, the strengths and limitations of each modality are discussed in this review. PMID:25234083

Severity of coronary artery disease in obese patients undergoing coronary angiography: "obesity paradox" revisited.

PubMed

Niraj, Ashutosh; Pradhan, Jyotiranjan; Pradahan, Jyotiranjan; Fakhry, Hesham; Veeranna, Vikas; Afonso, Luis

2007-08-01

Recent studies have highlighted the existence of an 'obesity paradox' in patients undergoing coronary angiography, i.e., a high body mass Index (BMI) is associated with less severe coronary lesions. We sought to confirm the existence of this phenomenon in the US patient population. Study subjects included 770 consecutive patients (470 men, 428 African-Americans, 212 Caucasians) referred for coronary angiography to a tertiary care center. Duke myocardial jeopardy score, a prognostication tool predictive of 1-year mortality in coronary artery disease (CAD) patients, was assigned to angiographic data. Patients were classified according to their BMI (kg/m2) as normal (21-24), overweight (25-29), obesity class I (30-34), class II (35-39) and class III (40 or above). Patients in the increasing obesity class had a higher prevalence of diabetes, hypertension and dyslipidemia and were more likely to be women. A negative correlation was observed between BMI and age (R = - 0.15 p < 0.001) as well as between BMI and Duke Jeopardy score (r = - 0.07, p < 0.05) indicating that patients with higher BMI were referred for coronary angiography at a younger age, and had a lower coronary artery disease (CAD) burden. BMI was not an independent predictor of coronary lesion severity on multivariate stepwise linear regression analysis. Obese patients are referred for coronary angiography at an earlier age and have a lower CAD burden lending further credence to the existence of an apparent "obesity paradox". However, obesity per se, after adjustment for comorbidities, is not an independent predictor of severity of coronary artery disease. (c) 2007 Wiley Periodicals, Inc.

Design and rationale of the AngioSeal versus the Radial approach In acute coronary SyndromE (ARISE) trial: a randomized comparison of a vascular closure device versus the radial approach to prevent vascular access site complications in non-ST-segment elevation acute coronary syndrome patients.

PubMed

de Andrade, Pedro Beraldo; E Mattos, Luiz Alberto Piva; Tebet, Marden André; Rinaldi, Fábio Salerno; Esteves, Vinícius Cardozo; Nogueira, Ederlon Ferreira; França, João Ítalo Dias; de Andrade, Mônica Vieira Athanazio; Barbosa, Robson Alves; Labrunie, André; Abizaid, Alexandre Antônio Cunha; Sousa, Amanda Guerra de Moraes Rego

2013-12-18

Arterial access is a major site of bleeding complications after invasive coronary procedures. Among strategies to decrease vascular complications, the radial approach is an established one. Vascular closure devices provide more comfort to patients and decrease hemostasis and need for bed rest. However, the inconsistency of data proving their safety limits their routine adoption as a strategy to prevent vascular complications, requiring evidence through adequately designed randomized trials. The aim of this study is to compare the radial versus femoral approach using a vascular closure device for the incidence of arterial puncture site vascular complications among non-ST-segment elevation acute coronary syndrome patients submitted to an early invasive strategy. ARISE is a national, multicenter, non-inferiority randomized clinical trial. Two hundred patients with non-ST-segment elevation acute coronary syndrome will be randomized to either radial or femoral access using a vascular closure device. The primary outcome is the occurrence of vascular complications at an arterial puncture site 30 days after the procedure, including major bleeding, retroperitoneal hematoma, compartment syndrome, hematoma ≥ 5 cm, pseudoaneurysm, arterio-venous fistula, infection, limb ischemia, arterial occlusion, adjacent nerve injury or the need for vascular surgical repair. Enrollment was initiated in September 2012, and until October 2013 91 patients were included. The inclusion phase is expected to last until the second half of 2014. The ARISE trial will help define the role of a vascular closure device as a bleeding avoidance strategy in patients with NSTEACS. ClinicalTrials.gov identifier: NCT01653587.

Appropriate Use Criteria for Coronary Revascularization and Trends in Utilization, Patient Selection and Appropriateness of Percutaneous Coronary Intervention

PubMed Central

Desai, Nihar R.; Bradley, Steven M.; Parzynski, Craig S.; Nallamothu, Brahmajee K.; Chan, Paul S.; Spertus, John A.; Patel, Manesh R.; Ader, Jeremy; Soufer, Aaron; Krumholz, Harlan M.; Curtis, Jeptha P.

2017-01-01

Importance Appropriate Use Criteria for coronary revascularization were developed to critically evaluate and improve patient selection for percutaneous coronary intervention (PCI). National trends in the appropriateness of PCI have not been examined. Objective To examine trends in PCI utilization, patient selection, and procedural appropriateness following the introduction of Appropriate Use Criteria. Design, Setting, Participants Multi-center, longitudinal, cross-sectional analysis of patients undergoing PCI between July 1, 2009 and December 31, 2014 at hospitals continuously participating in NCDR-CathPCI Registry over the study period. Main Outcome Measures Proportion of non-acute PCIs classified as inappropriate at the patient- and hospital-level using the 2012 Appropriate Use Criteria for Coronary Revascularization. Results A total of 2.7 million PCI procedures from 766 hospitals were included. Annual PCI volume for acute indications was consistent over the study period (2010: 377,540; 2014: 374,543), but the volume for non-acute PCIs decreased from 89,704 in 2010 to 59,375 in 2014. Among patients undergoing non-acute PCI, there were significant increases in angina severity (CCS III/IV angina, 15.8% and 38.4% in 2010 and 2014 respectively), use of anti-anginal medications prior to PCI (at least 2 anti-anginal medication, 22.3% and 35.1% in 2010 and 2014 respectively), and high-risk findings on non-invasive testing (22.2% and 33.2% in 2010 and 2014 respectively) (p<0.001 for all), but only modest increases in multivessel CAD (43.7% and 47.5% in 2010 and 2014 respectively, p<0.001). The proportion (95% CI) of non-acute PCIs classified as inappropriate decreased from 26.2% (95% CI, 25.8%–26.6%) to 13.3% (95% CI, 13.1%–13.6%) and the absolute number of inappropriate PCIs decreased from 21,781 to 7,921. Hospital-level variation in the proportion of PCIs classified as inappropriate was persistent over the study period (median 12.6%, IQR 5.9%–22.9% in 2014

Predictors of adherence to treatment by patients with coronary heart disease after percutaneous coronary intervention.

PubMed

Kähkönen, Outi; Saaranen, Terhi; Kankkunen, Päivi; Lamidi, Marja-Leena; Kyngäs, Helvi; Miettinen, Heikki

2018-03-01

To identify the predictors of adherence in patients with coronary heart disease after a percutaneous coronary intervention. Adherence is a key factor in preventing the progression of coronary heart disease. An analytical multihospital survey study. A survey of 416 postpercutaneous coronary intervention patients was conducted in 2013, using the Adherence of People with Chronic Disease Instrument. The instrument consists of 37 items measuring adherence and 18 items comprising sociodemographic, health behavioural and disease-specific factors. Adherence consisted of two mean sum variables: adherence to medication and a healthy lifestyle. Based on earlier studies, nine mean sum variables known to explain adherence were responsibility, cooperation, support from next of kin, sense of normality, motivation, results of care, support from nurses and physicians, and fear of complications. Frequencies and percentages were used to describe the data, cross-tabulation to find statistically significant background variables and multivariate logistic regression to confirm standardised predictors of adherence. Patients reported good adherence. However, there was inconsistency between adherence to a healthy lifestyle and health behaviours. Gender, close personal relationship, length of education, physical activity, vegetable and alcohol consumption, LDL cholesterol and duration of coronary heart disease without previous percutaneous coronary intervention were predictors of adherence. The predictive factors known to explain adherence to treatment were male gender, close personal relationship, longer education, lower LDL cholesterol and longer duration of coronary heart disease without previous percutaneous coronary intervention. Because a healthy lifestyle predicted factors known to explain adherence, these issues should be emphasised particularly for female patients not in a close personal relationship, with low education and a shorter coronary heart disease duration with previous

Effectiveness of atrial fibrillation as an independent predictor of death and coronary events in patients having coronary angiography.

PubMed

Marte, Thomas; Saely, Christoph H; Schmid, Fabian; Koch, Lorena; Drexel, Heinz

2009-01-01

The impact of atrial fibrillation (AF) on future coronary events is uncertain. In particular, the prognostic impact of AF in the clinically important population of coronary patients who undergo angiography is unknown. The aim of this study was to investigate (1) the prevalence of AF, (2) its association with coronary atherosclerosis, and (3) its impact on future coronary events in patients who undergo angiography. Electrocardiograms were evaluated in a consecutive series of 613 patients who underwent coronary angiography. Prospectively, death and cardiovascular events were recorded over 4.0 +/- 0.6 years. Among these patients, 37 (6%) at baseline had AF, and 576 (94%) were in sinus rhythm. The presence of AF was associated with a lower prevalence of coronary artery disease and of coronary diameter narrowing >or=50% on baseline angiography. However, prospectively, patients with AF were at a strongly increased risk for all-cause mortality (adjusted hazard ratio 5.15, 95% confidence interval 2.36 to 11.26, p <0.001), coronary death (hazard ratio 8.16, 95% confidence interval 2.89 to 23.09, p <0.001), and major coronary events (hazard ratio 3.80, 95% confidence interval 1.45 to 9.94, p = 0.007). In conclusion, although inversely associated with the presence of angiographically determined coronary atherosclerosis, AF is a strong predictor of death and future coronary events in patients with coronary artery disease who undergo coronary angiography.

Aneurysmal coronary artery disease: An overview

PubMed Central

ElGuindy, Mohamed S.

Aneurysmal coronary artery disease (ACAD) comprises both coronary artery aneurysms (CAA) and coronary artery ectasia (CAE). The reported prevalence of ACAD varies widely from 0.2 to 10%, with male predominance and a predilection for the right coronary artery (RCA). Atherosclerosis is the commonest cause of ACAD in adults, while Kawasaki disease is the commonest cause in children and adolescents, as well as in the Far East. Most patients are asymptomatic, but when symptoms do exist, they are usually related to myocardial ischemia. Coronary angiography is the mainstay of diagnosis, but follow up is best achieved using noninvasive imaging that does not involve exposure to radiation. The optimal management strategy in patients with ACAD remains controversial. Medical therapy is indicated for the vast majority of patients and includes antiplatelets and/or anticoagulants. Covered stents effectively limit further expansion of the affected coronary segments. Surgical ligation, resection, and coronary artery bypass grafting are appropriate for large lesions and for associated obstructive coronary artery disease. PMID:29564347

Duration of menopausal vasomotor symptoms over the menopause transition.

PubMed

Avis, Nancy E; Crawford, Sybil L; Greendale, Gail; Bromberger, Joyce T; Everson-Rose, Susan A; Gold, Ellen B; Hess, Rachel; Joffe, Hadine; Kravitz, Howard M; Tepper, Ping G; Thurston, Rebecca C

2015-04-01

The expected duration of menopausal vasomotor symptoms (VMS) is important to women making decisions about possible treatments. To determine total duration of frequent VMS (≥ 6 days in the previous 2 weeks) (hereafter total VMS duration) during the menopausal transition, to quantify how long frequent VMS persist after the final menstrual period (FMP) (hereafter post-FMP persistence), and to identify risk factors for longer total VMS duration and longer post-FMP persistence. The Study of Women's Health Across the Nation (SWAN) is a multiracial/multiethnic observational study of the menopausal transition among 3302 women enrolled at 7 US sites. From February 1996 through April 2013, women completed a median of 13 visits. Analyses included 1449 women with frequent VMS. Total VMS duration (in years) (hot flashes or night sweats) and post-FMP persistence (in years) into postmenopause. The median total VMS duration was 7.4 years. Among 881 women who experienced an observable FMP, the median post-FMP persistence was 4.5 years. Women who were premenopausal or early perimenopausal when they first reported frequent VMS had the longest total VMS duration (median, >11.8 years) and post-FMP persistence (median, 9.4 years). Women who were postmenopausal at the onset of VMS had the shortest total VMS duration (median, 3.4 years). Compared with women of other racial/ethnic groups, African American women reported the longest total VMS duration (median, 10.1 years). Additional factors related to longer duration of VMS (total VMS duration or post-FMP persistence) were younger age, lower educational level, greater perceived stress and symptom sensitivity, and higher depressive symptoms and anxiety at first report of VMS. Frequent VMS lasted more than 7 years during the menopausal transition for more than half of the women and persisted for 4.5 years after the FMP. Individual characteristics (eg, being premenopausal and having greater negative affective factors when first experiencing

Impact of high-sensitivity cardiac troponin I assays on patients presenting to an emergency department with suspected acute coronary syndrome.

PubMed

Yip, Thomas P Y; Pascoe, Heather M; Lane, Stephen E

2014-08-04

To determine whether introduction of high-sensitivity cardiac troponin I (hscTn-I) assays affected management of patients presenting with suspected acute coronary syndrome (ACS) to the emergency department (ED) of a tertiary referral hospital. A retrospective analysis of all patients presenting to the Geelong Hospital ED with suspected ACS from 23 April 2010 to 22 April 2013 -2 years before and 1 year after the changeover to hscTn-I assays on 23 April 2012. Hospital admission rates, time spent in the ED, rates of coronary angiography, rates of percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABGS), rates of discharge with a diagnosis of ACS, and rates of inhospital mortality. 12 360 consecutive patients presented with suspected ACS during the study period; 1897 were admitted to Geelong Hospital in the 2 years before and 944 in the 1 year after the changeover to hscTn-I assays. Comparing the two patient groups, there was no statistically significant difference in all-hospital admission rates (95% CI for the difference, - 3.1% to 0.3%; P = 0.10) or proportion of patients subsequently discharged with a diagnosis of ACS (95% CI for the difference, - 2.3% to 5.4%; P = 0.43). After the changeover, the median time patients spent in the ED was 11.5% shorter (3.85 h v 4.35 h; 95% CI for the difference, - 0.59 to - 0.43; P < 0.001) and the proportion of admitted patients undergoing coronary angiography was higher (53.4% v 45.2%; 95% CI for the difference, 4.3 to 12.0 percentage points; P < 0.001), but there was no statistically significant rise in the proportion of patients who had invasive treatment (PCI and/or CABGS) (95% CI for the difference, - 0.4% to 6.3%; P = 0.08). Inhospital mortality rates from ACS did not change significantly (95% CI for the difference, - 1.5% to 0.8%; P = 0.43). The introduction of hscTn-I assays appeared to be associated with more rapid diagnosis, resulting in less time spent in the ED, without a change in

Omega-3 versus isoflavones in the control of vasomotor symptoms in postmenopausal women.

PubMed

Palacios, S; Lilue, M; Mejia, A; Menendez, C

2017-12-01

Determine the efficacy and tolerability of omega-3 fatty acids versus soybean isoflavones in reducing the vasomotor symptoms (VMSs) frequency in postmenopausal women. A randomized, prospective, two-arm study was performed in healthy postmenopausal women aged 45-65. The two arms were: two capsules/day of omega-3 (425 mg of omega-3/capsule) administered orally (n = 38) and two tablets/day of soybean isoflavones (54.4 mg of isoflavones/tablet) (n = 30), over 16 weeks. The mean baseline frequency of moderate and severe VMSs per week in the omega-3 group was 24.56 and 23.90, respectively, and 19.65 and 19.51 in the isoflavone group. After 4 months, the reduction in moderate and severe hot flashes with omega-3 was significant (p < .001), whereas in the case of isoflavones, there was a significant difference in severe (p = .02) hot flashes after 4 months, but not in moderate hot flashes (p = .077). Omega-3 did not demonstrate significant efficacy differences versus isoflavones over time. The use of omega-3 has a beneficial effect on hot flash reduction after 4 months of treatment. This is comparable to the benefits found with soybean isoflavones after 3-4 weeks and after 4 months in severe hot flash women, but higher than those found with soybean isoflavones in moderate symptom women.

Regulation of Coronary Blood Flow

PubMed Central

Goodwill, Adam G.; Dick, Gregory M.; Kiel, Alexander M.; Tune, Johnathan D.

2018-01-01

The heart is uniquely responsible for providing its own blood supply through the coronary circulation. Regulation of coronary blood flow is quite complex and, after over 100 years of dedicated research, is understood to be dictated through multiple mechanisms that include extravascular compressive forces (tissue pressure), coronary perfusion pressure, myogenic, local metabolic, endothelial as well as neural and hormonal influences. While each of these determinants can have profound influence over myocardial perfusion, largely through effects on end-effector ion channels, these mechanisms collectively modulate coronary vascular resistance and act to ensure that the myocardial requirements for oxygen and substrates are adequately provided by the coronary circulation. The purpose of this series of Comprehensive Physiology is to highlight current knowledge regarding the physiologic regulation of coronary blood flow, with emphasis on functional anatomy and the interplay between the physical and biological determinants of myocardial oxygen delivery. PMID:28333376

Carotid and coronary disease management prior to open and endovascular aortic surgery. What are the current guidelines?

PubMed

Thompson, J P

2014-04-01

Several bodies produce broadly concurring and updated guidelines for the evaluation and treatment of cardiovascular disease in both surgical and non-surgical patients. Recent developments include revised recommendations on preoperative stress testing, referral for possible coronary revascularization and medical management. It is recognized that non-invasive cardiac tests are relatively poor at predicting perioperative risk, and "prophylactic" coronary revascularization has a limited role. The planned aortic intervention (open or endovascular repair) also influences preoperative management. Patients presenting for elective abdominal aortic aneurysm (AAA) repair should only be referred for cardiological testing if they have active symptoms of coronary artery disease (CAD), known CAD and poor functional exercise capacity, or multiple risk factors for CAD. Coronary revascularization before AAA surgery should be limited to patients with established indications, so cardiac stress testing should only be performed if it would change management i.e. the patient is a candidate for and would benefit from coronary revascularization. When endovascular aortic repair is planned, it is reasonable to proceed to surgery without further cardiac stress testing or evaluation unless otherwise indicated. All non-emergency patients require medical optimization, but perioperative beta blockade benefits only certain patients. Some of the data informing recent guidelines have been questioned and some guidelines are being revised. Current guidelines do not specifically address the management of patients with known or suspected carotid artery disease who may require aortic surgery. For these patients, an individualized approach is required. This review considers recent guidelines. Algorithms for investigation and management based on their recommendations are included.

Coronary tortuosity: a long and winding road

PubMed Central

Zegers, E.S.; Meursing, B.T.J.; Zegers, E.B.; Oude Ophuis, A.J.M.

2007-01-01

Coronary tortuosity is a phenomenon often encountered by cardiologists performing coronary angiography. The aetiology and clinical importance of coronary tortuosity are still unclear. Coronary tortuosity without fixed atherosclerotic stenosis in patients with angina pectoris and an abnormal exercise stress test has never been described in the literature. This article describes three cases of patients with anginal complaints, an abnormal exercise stress test and coronary angiography without the presence of a fixed atherosclerotic lesion. It is hypothesised that coronary tortuosity leads to flow alteration resulting in a reduction in coronary pressure distal to the tortuous segment of the coronary artery, subsequently leading to ischaemia. Future studies will be necessary to elucidate the actual mechanism of coronary tortuosity and its clinical significance. (Neth Heart J 2007;15:191-5.17612682) PMID:17612682

Coronary artery to pulmonary artery fistula.

PubMed

Dadkhah-Tirani, Heidar; Salari, Arsalan; Shafighnia, Shora; Hosseini, Seyed Fazel; Naghdipoor, Misa

2013-01-01

Male, 69 FINAL DIAGNOSIS: Coronary artery to pulmonary artery fistula Symptoms: Chest pain Medication: - Clinical Procedure: Echocardiography • angiography • surgical intervention Specialty: Cardiology • Cardiac Surgery. Rare disease. A coronary artery fistula is an abnormal communication between a coronary artery and one of the cardiac chambers or a great vessel, so bypassing the myocardial capillary network. They are usually discovered incidentally upon coronary angiography. Clinical manifestations are variable depending on the type of fistula, the severity of shunt, site of shunt, and presence of other cardiac condition. We report a 69-year-old man without any previous medical history, who was admitted to our hospital with chest pain. The electrocardiogram (ECG) showed a sinus rhythm with ST depression in V2 to V6 precordial leads. Coronary angiography revealed a coronary artery fistula from left anterior descending coronary artery (LAD) to the main pulmonary artery, right coronary artery blockage and significant stenoses on the LAD and left circumflex artery (LCX). Surgical treatment was chosen because of the total occlusion of the right coronary artery and to relieve of pain to improve quality of life.

CFD-based Thrombotic Risk Assessment in Kawasaki Disease Patients with Coronary Artery Aneurysms

NASA Astrophysics Data System (ADS)

Sengupta, Dibyendu; Kung, Ethan; Kahn, Andrew; Burns, Jane; Marsden, Alison

2012-11-01

Coronary aneurysms occur in 25% of untreated Kawasaki Disease (KD) patients and put patients at increased risk for myocardial infarction and sudden death. Clinical guidelines recommend using aneurysm diameter >8 mm as the arbitrary criterion for treating with anti-coagulation therapy. This study uses patient-specific modeling to non-invasively determine hemodynamic parameters and quantify thrombotic risk. Anatomic models were constructed from CT angiographic image data from 5 KD aneurysm patients and one normal control. CFD simulations were performed to obtain hemodynamic data including WSS and particle residence times (PRT). Thrombosis was clinically observed in 4/9 aneurysmal coronaries. Thrombosed vessels required twice as many cardiac cycles (mean 8.2 vs. 4.2) for particles to exit, and had lower mean WSS (1.3 compared to 2.8 dynes/cm2) compared to vessels with non-thrombosed aneurysms of similar max diameter. 1 KD patient in the cohort with acute thrombosis had diameter < 8 mm. Regions of low WSS and high PRT predicted by simulations correlated with regions of subsequent thrombus formation. Thrombotic risk stratification for KD aneurysms may be improved by incorporating both hemodynamic and geometric quantities. Current clinical guidelines to assess patient risk based only on aneurysm diameter may be misleading. Further prospective study is warranted to evaluate the utility of patient-specific modeling in risk stratifying KD patients with coronary aneurysms. NIH R21.

[MINOCA in Iceland. Acute coronary syndrome in patients with normal or nonobstructive coronary arteries].

PubMed

Vignisson, Saevar Thor; Gudmundsdottir, Ingibjorg Jona; Gudnason, Thorarinn; Danielsen, Ragnar; Gardarsdottir, Marianna; Andersen, Karl

2018-01-01

The classical pathophysiological process underlying acute coronary syndromes has been considered to be plaque rup-ture followed by platelet activation and aggregation and subsequent thrombus formation leading to myocardial ischemia and infarction. A substantial number of patients with acute coronary syndromes appear to have normal or near normal (<50% stenosis) coronary arteries on angiography. Recently, this clinical entity has been coined MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries). The purpose of this paper is to describe the proportion of MINOCA among ACS patients in Iceland. We performed a retrospective analysis of all admissions for acute coronary syndromes at Landspitali University Hospital, the single coronary catheterization facility in Iceland, during a five year period between 2012 and 2016. All patients admitted for STEMI or NSTEMI that turned out to have normal or near normal coronary arteries were consecutively included in the study. For each patient the diagnosis was re-evaluated according to further assessments using a diagnostic algorithm specially constructed for this study. During the five year study period 1708 patients were studied with coronary angiography during first hospitalization for STEMI or NSTEMI. Among these, 225 (13.2%) had normal or non-obstructive coronary arteries with less than 50% luminal narrowing. The final diagnosis of these patients were plaque erosion / rupture in 72 indi-viduals (32%), myocarditis in 33 (14.7%), takotsubo cardiomyopathy in 28 (12.4%), type II myocardial infarction in 30 (13.3%), vasospastic angina in 31 (13.8%) and other or undetermined cause in 31 (13.8%) patients. The proportion of MINOCA in Iceland is 13.2% of patients admitted for acute coronary syndromes. Plaque erosion / rupture was considered a likely cause in one third of patients with other causes beeing evenly distributed with approximately half that frequency. Identification of the underlying cause of MINOCA would

The prognostic value of CT coronary angiography in patients attending hospital with troponin-negative acute chest pain and inconclusive exercise treadmill tests.

PubMed

Mordi, Ify; Tzemos, Nikolaos

2016-05-01

Once acute coronary syndrome (ACS) is excluded in patients presenting to hospital with acute chest pain, usual practice is to stratify future risk of adverse cardiovascular events. Commonly this is performed by pre-discharge exercise treadmill testing (ETT). Often however, patients are unable to perform the test for various reasons, or the final result is inconclusive. This potentially could lead to uncertainty and to unnecessary invasive coronary angiography. We wished to evaluate the potential prognostic significance of CT coronary angiography (CTCA) in patients with prior inconclusive ETTs. Two hundred and thirty-two consecutive patients underwent CTCA and calcium scoring following hospital attendance with acute chest pain and following exclusion of ACS. All patients were followed up for a combined primary outcome of death, non-fatal myocardial infarction, and late revascularization. The mean follow-up period was 2.5 ± 0.9 years. The combined primary outcome occurred in 26 patients (11.2%). Calcium score (HR 1.16; 95% CI 1.02-1.31, P = 0.023 per 100 Agatston unit increase), the presence of coronary artery disease (CAD) on CTCA (non-obstructive CAD, HR 4.52; 95% CI 1.30-15.73, P = 0.018; obstructive CAD, HR 17.00; 95% CI 4.60-62.85, P < 0.001), and ≥3 segments with non-calcified plaque (HR 3.30; 95% CI 1.24-8.76, P = 0.017) were significant univariable predictors of the primary outcome. CTCA was the only significant multivariable predictor of adverse outcome. The presence of CAD assessed by CTCA is a strong predictor of adverse events in patients with troponin-negative acute chest pain and could potentially be used as an alternative, non-invasive risk stratifier in patients with inconclusive exercise tests. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

The diagnostic accuracy and outcomes after coronary computed tomography angiography vs. conventional functional testing in patients with stable angina pectoris: a systematic review and meta-analysis.

PubMed

Nielsen, Lene H; Ortner, Nino; Nørgaard, Bjarne L; Achenbach, Stephan; Leipsic, Jonathon; Abdulla, Jawdat

2014-09-01

To systematically review and perform a meta-analysis of the diagnostic accuracy and post-test outcomes of conventional exercise electrocardiography (XECG) and single-photon emission computed tomography (SPECT) compared with coronary computed tomography angiography (coronary CTA) in patients suspected of stable coronary artery disease (CAD). We systematically searched for studies published from January 2002 to February 2013 examining the diagnostic accuracy (defined as at least ≥50% luminal obstruction on invasive coronary angiography) and outcomes of coronary CTA (≥16 slice) in comparison with XECG and SPECT. The search revealed 11 eligible studies (N = 1575) comparing the diagnostic accuracy and 7 studies (N = 216.603) the outcomes of coronary CTA vs. XECG or/and SPECT. The per-patient sensitivity [95% confidence interval (95% CI)] to identify significant CAD was 98% (93-99%) for coronary CTA vs. 67% (54-78%) (P < 0.001) for XECG and 99% (96-100%) vs. 73% (59-83%) (P = 0.001) for SPECT. The specificity (95% CI) of coronary CTA was 82% (63-93%) vs. 46% (30-64%) (P < 0.001) for XECG and 71% (60-80%) vs. 48% (31-64%) (P = 0.14) for SPECT. The odds ratio (OR) of downstream test utilization (DTU) for coronary CTA vs. XECG/SPECT was 1.38 (1.33-1.43, P < 0.001), for revascularization 2.63 (2.50-2.77, P < 0.001), for non-fatal myocardial infarction 0.53 (0.39-0.72, P < 0.001), and for all-cause mortality 1.01 (0.87-1.18, P = 0.87). The up-front diagnostic performance of coronary CTA is higher than of XECG and SPECT. When compared with XECG/SPECT testing, coronary CTA testing is associated with increased DTU and coronary revascularization. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.

Augmented reality image guidance for minimally invasive coronary artery bypass

NASA Astrophysics Data System (ADS)

Figl, Michael; Rueckert, Daniel; Hawkes, David; Casula, Roberto; Hu, Mingxing; Pedro, Ose; Zhang, Dong Ping; Penney, Graeme; Bello, Fernando; Edwards, Philip

2008-03-01

We propose a novel system for image guidance in totally endoscopic coronary artery bypass (TECAB). A key requirement is the availability of 2D-3D registration techniques that can deal with non-rigid motion and deformation. Image guidance for TECAB is mainly required before the mechanical stabilization of the heart, thus the most dominant source of non-rigid deformation is the motion of the beating heart. To augment the images in the endoscope of the da Vinci robot, we have to find the transformation from the coordinate system of the preoperative imaging modality to the system of the endoscopic cameras. In a first step we build a 4D motion model of the beating heart. Intraoperatively we can use the ECG or video processing to determine the phase of the cardiac cycle. We can then take the heart surface from the motion model and register it to the stereo-endoscopic images of the da Vinci robot using 2D-3D registration methods. We are investigating robust feature tracking and intensity-based methods for this purpose. Images of the vessels available in the preoperative coordinate system can then be transformed to the camera system and projected into the calibrated endoscope view using two video mixers with chroma keying. It is hoped that the augmented view can improve the efficiency of TECAB surgery and reduce the conversion rate to more conventional procedures.

Platelet counts on admission affect coronary flow, myocardial perfusion and left ventricular systolic function after primary percutaneous coronary intervention.

PubMed

Sharif, Dawod; Abu-Salem, Mira; Sharif-Rasslan, Amal; Rosenschein, Uri

2017-10-01

Patients with acute ST-elevation myocardial infarction (STEMI) and increased platelet count treated by fibrinolysis have worse outcomes. The aim of this study was to test the hypothesis that platelet blood count at admission in patients with acute STEMI treated by primary percutaneous coronary intervention affects coronary flow, myocardial perfusion and recovery of left ventricular systolic function. A total of 174 patients presenting with acute anterior STEMI and treated with primary percutaneous coronary intervention were included and divided into subgroups of admission platelet blood count of <200 K, 200-300 K, 300-400 K and >400 K. Evaluation of coronary artery flow and myocardial blush grade was performed according to the TIMI criteria. Electrocardiographic ST elevation resolution post-primary percutaneous coronary intervention was evaluated. Doppler echocardiographic evaluation of left anterior descending coronary artery velocities early and late after primary percutaneous coronary intervention and assessment of left ventricular ejection fraction and wall motion score index (WMSI) of left ventricular and left anterior descending coronary artery territory were performed. Post-primary percutaneous coronary intervention TIMI, myocardial blush grade and ST elevation resolution were similar in all groups. Patients with platelet counts <200 K had higher peak diastolic left anterior descending coronary artery velocity both early and late after primary percutaneous coronary intervention, and higher prevalence of left anterior descending coronary artery velocity deceleration time exceeding 600 ms, (45.5% vs. 40%, P<0.05). Patients with platelet counts >400 K presented with worse left ventricular ejection fraction, left ventricular WMSI and left anterior descending coronary artery WMSI, and before discharge this subgroup had worse left ventricular WMSI and left anterior descending coronary artery WMSI, P<0.01. Patients with anterior STEMI treated by primary

Single left coronary ostium and an anomalous prepulmonic right coronary artery in 2 dogs with congenital pulmonary valve stenosis.

PubMed

Visser, Lance C; Scansen, Brian A; Schober, Karsten E

2013-06-01

A coronary artery anomaly characterized by the presence of a single left coronary ostium with absence of the right coronary ostium and an anomalous prepulmonic right coronary artery course was observed in two dogs with concurrent congenital pulmonary valve stenosis. This unique coronary artery anatomy is similar to the previously described single right coronary ostium with anomalous prepulmonic left coronary artery, the so-called type R2A anomaly, in that an anomalous coronary artery encircles the pulmonary valve annulus. Both dogs of this report, a boxer and an English bulldog, were of breeds known to be at risk for the type R2A anomaly. As such, veterinarians should be aware that the echocardiographic presence of a left coronary ostium in a dog with pulmonary valve stenosis does not exclude the possibility of a prepulmonic coronary artery anomaly that may enhance the risk of complications during balloon pulmonary valvuloplasty. A descriptive naming convention for coronary artery anomalies in dogs is also presented, which may be preferable to the older coding classification scheme. Copyright © 2013 Elsevier B.V. All rights reserved.

Application of Near Infrared Spectroscopy, Intravascular Ultrasound and the Coronary Calcium Score to Predict Adverse Coronary Events

DTIC Science & Technology

2012-10-01

hospitalization 9. Emergence of rhythm disturbances requiring treatment 10. Development of acute coronary syndrome 11. Cerebrovascular accident Adverse...catheterization. These will include coronary injury including dissection, perforation or occlusion, death, cerebrovascular accident , myocardial... cerebrovascular accident , bleeding, infection, arrhythmia, access site damage, coronary dissection, coronary thrombosis and myocardial infarction, among

The presence of African American race predicts improvement in coronary endothelial function after supplementary L-arginine.

PubMed

Houghton, Jan L; Philbin, Edward F; Strogatz, David S; Torosoff, Mikhail T; Fein, Steven A; Kuhner, Patricia A; Smith, Vivienne E; Carr, Albert A

2002-04-17

The purpose of our study was to determine if the presence of African American ethnicity modulates improvement in coronary vascular endothelial function after supplementary L-arginine. Endothelial dysfunction is an early stage in the development of coronary atherosclerosis and has been implicated in the pathogenesis of hypertension and cardiomyopathy. Amelioration of endothelial dysfunction has been demonstrated in patients with established coronary atherosclerosis or with risk factors in response to infusion of L-arginine, the precursor of nitric oxide. Racial and gender patterns in L-arginine responsiveness have not, heretofore, been studied. Invasive testing of coronary artery and microvascular reactivity in response to graded intracoronary infusions of acetylcholine (ACh) +/- L-arginine was carried out in 33 matched pairs of African American and white subjects with no angiographic coronary artery disease. Pairs were matched for age, gender, indexed left ventricular mass, body mass index and low-density lipoprotein cholesterol. In addition to the matching parameters, there were no significant differences in peak coronary blood flow (CBF) response to intracoronary adenosine or in the peak CBF response to ACh before L-arginine infusion. However, absolute percentile improvement in CBF response to ACh infusion after L-arginine, as compared with before, was significantly greater among African Americans as a group (45 +/- 10% vs. 4 +/- 6%, p = 0.0016) and after partitioning by gender. The mechanism of this increase was mediated through further reduction in coronary microvascular resistance. L-arginine infusion also resulted in greater epicardial dilator response after ACh among African Americans. We conclude that intracoronary infusion of L-arginine provides significantly greater augmentation of endothelium-dependent vascular relaxation in those of African American ethnicity when compared with matched white subjects drawn from a cohort electively referred for coronary

Morphometry of the coronary ostia and the structure of coronary arteries in the shorthair domestic cat

PubMed Central

Barszcz, Karolina; Kupczyńska, Marta; Klećkowska-Nawrot, Joanna; Janeczek, Maciej; Goździewska-Harłajczuk, Karolina; Dzierzęcka, Małgorzata; Janczyk, Paweł

2017-01-01

The aim of this study was to measure the area of the coronary ostia, assess their localization in the coronary sinuses and to determine the morphology of the stem of the left and right coronary arteries in the domestic shorthair cat. The study was conducted on 100 hearts of domestic shorthair cats of both sexes, aged 2–18 years, with an average body weight of 4.05 kg. A morphometric analysis of the coronary ostia was carried out on 52 hearts. The remaining 48 hearts were injected with a casting material in order to carry out a morphological assessment of the left and right coronary arteries. In all the studied animals, the surface of the left coronary artery ostium was larger than the surface of the right coronary artery ostium. There were four types of the left main coronary artery: type I (23 animals, 49%)–double-branched left main stem (giving off the left circumflex branch and the interventricular paraconal branch, which in turn gave off the septal branch), type II (12 animals, 26%)–double-branched left main stem (giving off the left circumflex branch and the interventricular paraconal branch without the septal branch), type III (11 animals, 23%)–triple-branched left main stem (giving off the left circumflex branch, interventricular branch and the septal branch, type IV (1 animal, 2%)–double-branched left main stem (giving off the interventricular paraconal branch and the left circumflex branch, which in turn gave off the septal branch). The left coronary artery ostium is greater than the right one. There is considerable diversity in the branches of proximal segment of the left coronary artery, while the right coronary artery is more conservative. These results can be useful in defining the optimal strategies in the endovascular procedures involving the coronary arteries or the aortic valve in the domestic shorthair cat. PMID:29020103

Elevated Levels of Serum Fibrin and Fibrinogen Degradation Products Are Independent Predictors of Larger Coronary Plaques and Greater Plaque Necrotic Core

PubMed Central

Corban, Michel T; Hung, Olivia Y; Mekonnen, Girum; Eshtehardi, Parham; Eapen, Danny J; Rasoul-Arzrumly, Emad; Kassem, Hatem Al; Manocha, Pankaj; Ko, Yi-An; Sperling, Laurence S; Quyyumi, Arshed A; Samady, Habib

2016-01-01

Background Co-existence of vulnerable plaque and pro-thrombotic state may provoke acute coronary events. It was hypothesized that elevated serum levels of fibrin and fibrinogen degradation products (FDP) are associated with larger total plaque and necrotic core (NC) areas. Methods and Results Seventy-five patients presenting with stable anginal symptoms (69%) or stabilized acute coronary syndrome (ACS; 31%), and found to have non-obstructive coronary artery disease (CAD) with a fractional flow reserve >0.8, were studied. Invasive virtual histology intravascular ultrasound (VH-IVUS) was performed in 68 LAD arteries, 6 circumflex arteries, and 1 right coronary artery. Serum FDP levels were measured using ELISA technique. Plaque volumetrics and composition were assessed in each VH-IVUS frame and averaged. The median age of patients was 56 (47–63) years; 52% were men and 23% had diabetes. The average length of coronary artery studied was 62 mm. After adjustment for systemic risk factors, medications, CRP levels and ACS, male gender (P<0.001) and serum FDP levels (P=0.02) were independent predictors of a larger NC area. Older age (P<0.001), male gender (P<0.0001) and increased serum FDP level (P=0.03) were associated with a larger plaque area. Conclusions In patients with CAD, a higher serum level of FDP is independently associated with larger plaques and greater plaque NC. PMID:26911453

Elevated Levels of Serum Fibrin and Fibrinogen Degradation Products Are Independent Predictors of Larger Coronary Plaques and Greater Plaque Necrotic Core.

PubMed

Corban, Michel T; Hung, Olivia Y; Mekonnen, Girum; Eshtehardi, Parham; Eapen, Danny J; Rasoul-Arzrumly, Emad; Al Kassem, Hatem; Manocha, Pankaj; Ko, Yi-An; Sperling, Laurence S; Quyyumi, Arshed A; Samady, Habib

2016-01-01

Co-existence of vulnerable plaque and pro-thrombotic state may provoke acute coronary events. It was hypothesized that elevated serum levels of fibrin and fibrinogen degradation products (FDP) are associated with larger total plaque and necrotic core (NC) areas. Seventy-five patients presenting with stable anginal symptoms (69%) or stabilized acute coronary syndrome (ACS; 31%), and found to have non-obstructive coronary artery disease (CAD) with a fractional flow reserve >0.8, were studied. Invasive virtual histology intravascular ultrasound (VH-IVUS) was performed in 68 LAD arteries, 6 circumflex arteries, and 1 right coronary artery. Serum FDP levels were measured using ELISA technique. Plaque volumetrics and composition were assessed in each VH-IVUS frame and averaged. The median age of patients was 56 (47-63) years; 52% were men and 23% had diabetes. The average length of coronary artery studied was 62 mm. After adjustment for systemic risk factors, medications, CRP levels and ACS, male gender (P<0.001) and serum FDP levels (P=0.02) were independent predictors of a larger NC area. Older age (P<0.001), male gender (P<0.0001) and increased serum FDP level (P=0.03) were associated with a larger plaque area. In patients with CAD, a higher serum level of FDP is independently associated with larger plaques and greater plaque NC.

Usefulness of coronary calcium scoring to myocardial perfusion SPECT in the diagnosis of coronary artery disease in a predominantly high risk population.

PubMed

Schaap, Jeroen; Kauling, Robert M; Boekholdt, S Matthijs; Post, Martijn C; Van der Heyden, Jan A; de Kroon, Thom L; van Es, H Wouter; Rensing, Benno J W M; Verzijlbergen, J Fred

2013-03-01

Coronary calcium scoring (CCS) adds to the diagnostic performance of myocardial perfusion single-photon emission computed tomography (SPECT) to assess the presence of significant coronary artery disease (CAD). Patients with a high pre-test likelihood are expected to have a high CCS which potentially could enhance the diagnostic performance of myocardial perfusion SPECT in this specific patient group. We evaluated the added value of CCS to SPECT in the diagnosis of significant CAD in patients with an intermediate to high pre-test likelihood. In total, 129 patients (mean age 62.7 ± 9.7 years, 65 % male) with stable anginal complaints and intermediate to high pre-test likelihood of CAD (median 87 %, range 22-95) were prospectively included in this study. All patients received SPECT and CCS imaging preceding invasive coronary angiography (CA). Fractional flow reserve (FFR) measurements were acquired from patients with angiographically estimated 50-95 % obstructive CAD. For SPECT a SSS > 3 was defined significant CAD. For CCS the optimal cut-off value for significant CAD was determined by ROC curve analysis. The reference standard for significant CAD was a FFR of <0.80 acquired by CA. Significant CAD was demonstrated in 64 patients (49.6 %). Optimal CCS cut-off value for significant CAD was >182.5. ROC curve analysis for prediction of the presence of significant CAD for SPECT, CCS and the combination of CCS and SPECT resulted in an area under the curve (AUC) of 0.88 (95 % CI 81-94), 0.75 (95 % CI 66-83 %) and 0.92 (95 % CI 87-97 %) respectively. The difference of the AUC between SPECT and the combination of CCS and SPECT was 0.05 (P = 0.12). The addition of CCS did not significantly improve the diagnostic performance of SPECT in the evaluation of patients with a predominantly high pre-test likelihood of CAD.

Cost-effectiveness of 64-slice CT angiography compared to conventional coronary angiography based on a coverage with evidence development study in Ontario.

PubMed

Goeree, Ron; Blackhouse, Gord; Bowen, James M; O'Reilly, Daria; Sutherland, Simone; Hopkins, Robert; Chow, Benjamin; Freeman, Michael; Provost, Yves; Dennie, Carole; Cohen, Eric; Marcuzzi, Dan; Iwanochko, Robert; Moody, Alan; Paul, Narinder; Parker, John D

2013-10-01

Conventional coronary angiography (CCA) is the standard diagnostic for coronary artery disease (CAD), but multi-detector computed tomography coronary angiography (CTCA) is a non-invasive alternative. A multi-center coverage with evidence development study was undertaken and combined with an economic model to estimate the cost-effectiveness of CTCA followed by CCA vs CCA alone. Alternative assumptions were tested in patient scenario and sensitivity analyses. CCA was found to dominate CTCA, however, CTCA was relatively more cost-effective in females, in advancing age, in patients with lower pre-test probabilities of CAD, the higher the sensitivity of CTCA and the lower the probability of undergoing a confirmatory CCA following a positive CTCA. RESULTS were very sensitive to alternative patient populations and modeling assumptions. Careful consideration of patient characteristics, procedures to improve the diagnostic yield of CTCA and selective use of CCA following CTCA will impact whether CTCA is cost-effective or dominates CCA.

Coronary Endarterectomy: Recent Trends.

PubMed

Ghatanatti, Ravi; Teli, Anita

2017-08-01

Coronary Endarterectomy (CE) assures complete revascularization of the myocardium in case of diffusely diseased vessels and prevents residual ischemia. Recently cardiac surgeons are performing increasing number of coronary endarterectomy and it has evolved as an important adjuvant procedure in Coronary Artery Bypass Grafting (CABG). There are controversies regarding the efficiency of CE. CE is criticised for its higher rates of morbidity and mortality. At present the available evidence supports CE in Off Pump Coronary Artery Bypass surgery (OPCAB) and along with valvular procedures. Graft patency is better with open technique. Postoperative anticoagulation regimen though not uniform, the overall outcome remains the same. Therefore, it is important to focus on the current results to accept CE as a routine procedure like CABG.

Multidecade-long trends (1986-2005) in the utilization of coronary reperfusion and revascularization treatment strategies in patients hospitalized with acute myocardial infarction

PubMed Central

Wasser, Jared; Goldberg, Robert J.; Spencer, Frederick A.; Yarzebski, Jorge; Gore, Joel M.

2009-01-01

Objectives The objectives of our community-wide investigation were to describe multidecade-long trends (1986-2005) in the utilization of thrombolytic therapy, percutaneous coronary interventions, and coronary artery bypass graft surgery in patients hospitalized with acute myocardial infarction (AMI). Methods The study sample consisted of 9422 greater Worcester (MA) residents hospitalized with confirmed AMI at all metropolitan Worcester medical centers in 11 annual periods between 1986 and 2005. Results Increases in the utilization of percutaneous coronary interventions were observed between 1986 (2.0%) and 2005 (50.7%) with the most rapid increases beginning in the late 1990s. Utilization of coronary artery bypass graft surgery during hospitalization for AMI increased moderately in the 1990s, remained stable thereafter, and declined to being performed in 3.8% of hospitalized patients in 2005. The use of thrombolytic therapy increased between 1986 and 1995 (9.3-25.2%) and decreased markedly thereafter through 2005 (< 1%). Demographic and clinical characteristics of several patients were associated with the receipt of these treatment regimens. Conclusion The results of this study in residents of a large Central New England community suggest an increasingly invasive approach to the management of patients hospitalized with AMI. PMID:19050597

Mechanisms underlying capsaicin effects in canine coronary artery: implications for coronary spasm

PubMed Central

Hiett, S. Christopher; Owen, Meredith K.; Li, Wennan; Chen, Xingjuan; Riley, Ashley; Noblet, Jillian; Flores, Sarah; Sturek, Michael; Tune, Johnathan D.; Obukhov, Alexander G.

2014-01-01

Aims The TRPV1, transient receptor potential vanilloid type 1, agonist capsaicin is considered to be beneficial for cardiovascular health because it dilates coronary arteries through an endothelial-dependent mechanism and may slow atheroma progression. However, recent reports indicate that high doses of capsaicin may constrict coronary arterioles and even provoke myocardial infarction. Thus far, the mechanisms by which TRPV1 activation modulates coronary vascular tone remain poorly understood. This investigation examined whether there is a synergistic interplay between locally acting vasoconstrictive pro-inflammatory hormones (autacoids) and capsaicin effects in the coronary circulation. Methods and results Experiments were performed in canine conduit coronary artery rings and isolated smooth muscle cells (CASMCs). Isometric tension measurements revealed that 1–10 μM capsaicin alone did not affect resting tension of coronary artery rings. In contrast, in endothelium-intact rings pre-contracted with a Gq/11-coupled FP/TP (prostaglandin F/thromboxane) receptor agonist, prostaglandin F2α (PGF2α; 10 μM), capsaicin first induced transient dilation that was followed by sustained contraction. In endothelium-denuded rings pre-contracted with PGF2α or thromboxane analogue U46619 (1 μM, a TP receptor agonist), capsaicin induced only sustained contraction. Blockers of the TP receptor or TRPV1 significantly inhibited capsaicin effects, but these were still observed in the presence of 50 μM nifedipine and 70 mM KCl. Capsaicin also potentiated 20 mM KCl-induced contractions. Fluorescence imaging experiments in CASMCs revealed that the Gq/11-phospholipase C (PLC)-protein kinase C (PKC) and Ca2+-PLC-PKC pathways are likely involved in sensitizing CASMC TRPV1 channels. Conclusion Capsaicin alone does not cause contractions in conduit canine coronary artery; however, pre-treatment with pro-inflammatory prostaglandin–thromboxane agonists may unmask capsaicin

Cardiac Society of Australia and New Zealand Position Statement: Coronary Artery Calcium Scoring.

PubMed

Liew, Gary; Chow, Clara; van Pelt, Niels; Younger, John; Jelinek, Michael; Chan, Jonathan; Hamilton-Craig, Christian

2017-12-01

Coronary Artery Calcium Scoring (CAC) is a non-invasive quantitation of coronary artery calcification using computed tomography (CT). It is a marker of atherosclerotic plaque burden and an independent predictor of future myocardial infarction and mortality. Coronary Artery Calcium Scoring provides incremental risk information beyond traditional risk calculators (eg. Framingham Risk Score). Its use for risk stratification is confined to primary prevention of cardiovascular events, and can be considered as "individualised coronary risk scoring" for those not considered to be of high or low risk. Medical practitioners should carefully counsel patients prior to CAC. Coronary Artery Calcium Scoring should only be undertaken if an alteration in therapy including embarking on pharmacotherapy is being considered based on the test result. Patient Groups to Consider Coronary Calcium Scoring: Patient Groups in Whom Coronary Calcium Scoring Should Not be Considered: Coronary Artery Calcium Scoring is not recommended for patients who are: Interpretation of CAC CAC=0 A zero score confers a very low risk of death, <1% at 10 years. CAC=1-100 Low risk, <10% CAC=101-400 Intermediate risk, 10-20% CAC=101-400 & >75th centile. Moderately high risk, 15-20% CAC >400 High risk, >20% Management Recommendations Based on CAC Optimal diet and lifestyle measures are encouraged in all risk groups and form the basis of primary prevention strategies. Patients with moderately-high or high risk based on CAC score are recommended to receive preventative medical therapy such as aspirin and statins. The evidence for pharmacotherapy is less robust in patients at intermediate levels of CAC 100-400, with modest benefit for aspirin use; though statins may be reasonable if they are above 75th centile. Aspirin and statins are generally not recommended in patients with CAC <100. Repeat CAC Testing In patients with a CAC of 0, a repeat CAC may be considered in 5 years but not sooner. In patients with positive

Weather/temperature-sensitive vasomotor rhinitis may be refractory to intranasal corticosteroid treatment.

PubMed

Jacobs, Robert; Lieberman, Philip; Kent, Edward; Silvey, MaryJane; Locantore, Nicholas; Philpot, Edward E

2009-01-01

Vasomotor rhinitis (VMR) is a common but poorly understood disorder of which there are two major subgroups: VMR(w/t), triggered by weather/temperature and VMR(ir), triggered by airborne irritants. No specific biological pathways or specific treatments for VMR(w/t) or VMR(ir) have been identified. However, intranasal corticosteroids (INSs) are effective in treating many forms of nonallergic rhinitis that include these conditions. A recently introduced INS with established efficacy in allergic rhinitis and enhanced affinity, fluticasone furoate, may possess the potency and safety profile required to treat chronic VMR(w/t). Two replicate studies (FFR30006 and FFR30007) were conducted in six countries to evaluate the efficacy and safety of fluticasone furoate nasal spray in subjects with VMR(w/t). After a 7- to 14-day screening period, subjects (n = 699) with symptomatic VMR(w/t) received fluticasone furoate, 110 mug q.d. or placebo for 4 weeks in these two randomized, double-blind, parallel-group studies. Subjects rated their nasal symptoms (congestion, rhinorrhea, and postnasal drip) twice daily on a 4-point categorical scale and evaluated their overall response to treatment at study end. Fluticasone furoate did not significantly improve daily reflective total nasal symptom scores, the primary end point, versus placebo (p = 0.259) and there was no improvement in any other measure of efficacy. The active treatment was well tolerated. Fluticasone furoate was not effective in treating subjects with a newly defined condition, weather-sensitive VMR. These unexpected results suggest that VMR(w/t) is a distinct subgroup of VMR that is refractory to treatment with INSs. Additional study of other treatments for VMR(w/t) (including INSs) is warranted.

Do Indo-Asians have smaller coronary arteries?

PubMed

Lip, G Y; Rathore, V S; Katira, R; Watson, R D; Singh, S P

1999-08-01

There is a widespread belief that coronary arteries are smaller in Indo-Asians. The aim of the present study was to compare the size of atheroma-free proximal and distal epicardial coronary arteries of Indo-Asians and Caucasians. We analysed normal coronary angiograms from 77 Caucasians and 39 Indo-Asians. The two groups were comparable for dominance of the coronary arteries. Indo-Asian patients had generally smaller coronary arteries, with a statistically significant difference in the mean diameters of the left main coronary artery, proximal, mid and left anterior descending, and proximal and distal right coronary artery segments. There was a non-significant trend towards smaller coronary artery segment diameters for the distal left anterior descending, proximal and distal circumflex, and obtuse marginal artery segments. However, after correction for body surface area, none of these differences in size were statistically significant. Thus, the smaller coronary arteries in Indo-Asian patients were explained by body size alone and were not due to ethnic origin per se. This finding nevertheless has important therapeutic implications, since smaller coronary arteries may give rise to technical difficulties during bypass graft and intervention procedures such as percutaneous transluminal coronary angioplasty, stents and atherectomy. On smaller arteries, atheroma may also give an impression of more severe disease than on larger diameter arteries.

Percutaneous Coronary Intervention for a Patient with Left Main Coronary Compression Syndrome.

PubMed

Ikegami, Ryutaro; Ozaki, Kazuyuki; Ozawa, Takuya; Hirono, Satoru; Ito, Masahiro; Minamino, Tohru

2018-05-15

Left main coronary compression syndrome rarely occurs in patients with severe pulmonary hypertension. A 65-year-old woman with severe pulmonary hypertension due to an atrial septal defect suffered from angina on effort. Cardiac computed-tomography and coronary angiography revealed considerable stenosis of the left main coronary artery (LMA) caused by compression between the dilated main pulmonary artery trunk and the sinus of valsalva. Stenting of the LMA under intravascular ultrasound imaging was effective for the treatment of angina. We herein report the diagnosis and management of this condition with a brief literature review.

Association between the severity of coronary artery stenosis and the combination of the difference in blood pressure between arms and brachial-ankle pulse wave velocity.

PubMed

Miyase, Yuiko; Miura, Shin-Ichiro; Shiga, Yuhei; Yano, Masaya; Suematsu, Yasunori; Adachi, Sen; Norimatsu, Kenji; Nakamura, Ayumi; Saku, Keijiro

2016-01-01

A difference in systolic blood pressure (SBP) ≥10 mmHg between the arms is associated with an increased risk of coronary artery disease (CAD) and mortality in high-risk patients. Four hundred and fourteen patients were divided into three groups according to the percent most severe luminal narrowing of a coronary artery as diagnosed by coronary computed tomography angiography: no or mild coronary stenosis (0-49%), moderate stenosis (50-69%) and severe stenosis (≥70%) groups. The relative difference in SBP between arms in the severe group was significantly lower than those in the no or mild and moderate groups. The brachial-ankle pulse wave velocity (baPWV) significantly increased as the severity of coronary stenosis increased. We confirmed that severe coronary stenosis was independently associated with both the relative difference in SBP between arms and baPWV, in addition to age, gender, hypertension, dyslipidemia, diabetes mellitus and ankle-brachial index by a logistic regression analysis. The group with a relative difference in SBP between arms of <1 mmHg and baPWV ≥ 1613 cm/s showed a higher percentage of patients with severe coronary stenosis than groups that met neither or only one of these criteria. The combination of the relative difference in SBP between arms and baPWV may be a more effective approach for the non-invasive assessment of the severity of CAD.

Resting multilayer 2D speckle-tracking TTE for detection of ischemic segments confirmed by invasive FFR part-2, using post-systolic-strain-index and time from aortic-valve-closure to regional peak longitudinal-strain.

PubMed

Ozawa, Koya; Funabashi, Nobusada; Nishi, Takeshi; Takahara, Masayuki; Fujimoto, Yoshihide; Kamata, Tomoko; Kobayashi, Yoshio

2016-08-15

This study evaluated the post-systolic strain index (PSI), and the time interval between aortic valve closure (AVC) and regional peak longitudinal strain (PLS), measured by transthoracic echocardiography (TTE), for detection of left ventricular (LV) myocardial ischemic segments confirmed by invasive fractional flow reserve (FFR). 39 stable patients (32 males; 65.8±11.9years) with 46 coronary arteries at ≥50% stenosis on invasive coronary angiography underwent 2D speckle tracking TTE (Vivid E9, GE Healthcare) and invasive FFR measurements. PSI, AVC and regional PLS in each LV segment were calculated. FFR ≤0.80 was detected in 27 LV segments. There were no significant differences between segments supplied by FFR ≤0.80 and FFR >0.80 vessels in either PSI or the time interval between AVC and regional PLS. To identify LV segments±FFR ≤0.80, the receiver operator characteristic (ROC) curves for PSI, and the time interval between AVC and regional PLS had areas under the curve (AUC) values of 0.58 and 0.57, respectively, with best cut-off points of 12% (sensitivity 70.4%, specificity 57.9%) and 88ms (sensitivity 70.4%, specificity 52.6%), respectively, but the AUCs were not statistically significant. In stable coronary artery disease patients with ≥50% coronary artery stenosis, measurement of PSI, and the time interval between AVC and regional PLS, on resting TTE, enabled the identification of LV segments with FFR ≤0.80 using each appropriate threshold for PSI, and the time interval between AVC and regional PLS, with reasonable diagnostic accuracy. However, the AUC values were not statistically significant. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

[Brief history of percutaneous coronary intervention].

PubMed

Song, Zhi-yuan; Zhang, Zhi-ying; Xu, Ze-sheng

2010-05-01

Percutaneous coronary intervention (PCI) is that delivering balloon catheter and/or equipment such as a stent to the target coronary artery bypass peripheral artery, at the same time, expanding and opening the stenosis of coronary artery. Through several decades of development, PCI has become a most effective way to rescue patients with coronary heart disease and become one of the biggest advances in the field of heart disease. Because of the development of PCI, more lives have been saved in patients with coronary heart disease. However, PCI does not meet the point of perfection, still has a lot of issues remain to be further resolved. Through a review the development of PCI, we may be able to get some insights to perfect the treatment technique for the patients of coronary heart disease.

Hemodynamic analysis of sequential graft from right coronary system to left coronary system.

PubMed

Wang, Wenxin; Mao, Boyan; Wang, Haoran; Geng, Xueying; Zhao, Xi; Zhang, Huixia; Xie, Jinsheng; Zhao, Zhou; Lian, Bo; Liu, Youjun

2016-12-28

Sequential and single grafting are two surgical procedures of coronary artery bypass grafting. However, it remains unclear if the sequential graft can be used between the right and left coronary artery system. The purpose of this paper is to clarify the possibility of right coronary artery system anastomosis to left coronary system. A patient-specific 3D model was first reconstructed based on coronary computed tomography angiography (CCTA) images. Two different grafts, the normal multi-graft (Model 1) and the novel multi-graft (Model 2), were then implemented on this patient-specific model using virtual surgery techniques. In Model 1, the single graft was anastomosed to right coronary artery (RCA) and the sequential graft was adopted to anastomose left anterior descending (LAD) and left circumflex artery (LCX). While in Model 2, the single graft was anastomosed to LAD and the sequential graft was adopted to anastomose RCA and LCX. A zero-dimensional/three-dimensional (0D/3D) coupling method was used to realize the multi-scale simulation of both the pre-operative and two post-operative models. Flow rates in the coronary artery and grafts were obtained. The hemodynamic parameters were also showed, including wall shear stress (WSS) and oscillatory shear index (OSI). The area of low WSS and OSI in Model 1 was much less than that in Model 2. Model 1 shows optimistic hemodynamic modifications which may enhance the long-term patency of grafts. The anterior segments of sequential graft have better long-term patency than the posterior segments. With rational spatial position of the heart vessels, the last anastomosis of sequential graft should be connected to the main branch.

Influence of inpatient service specialty on care processes and outcomes for patients with non ST-segment elevation acute coronary syndromes.

PubMed

Roe, Matthew T; Chen, Anita Y; Mehta, Rajendra H; Li, Yun; Brindis, Ralph G; Smith, Sidney C; Rumsfeld, John S; Gibler, W Brian; Ohman, E Magnus; Peterson, Eric D

2007-09-04

Since the broad dissemination of practice guidelines, the association of specialty care with the treatment of patients with acute coronary syndromes has not been studied. We evaluated 55 994 patients with non-ST-segment elevation acute coronary syndromes (ischemic ST-segment changes and/or positive cardiac markers) included in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Quality Improvement Initiative from January 2001 through September 2003 at 301 tertiary US hospitals with full revascularization capabilities. We compared baseline characteristics, the use of American College of Cardiology/American Heart Association guidelines class I recommendations, and in-hospital outcomes by the specialty of the primary in-patient service (cardiology versus noncardiology). A total of 35 374 patients (63.2%) were primarily cared for by a cardiology service, and these patients had lower-risk clinical characteristics, but they more commonly received acute (invasive cardiac procedures, and discharge medications and lifestyle interventions. Acute care processes were improved when care was provided by a cardiology service regardless of the propensity to receive cardiology care. The adjusted risk of in-hospital mortality was lower with care provided by a cardiology service (adjusted odds ratio 0.80, 95% confidence interval 0.73 to 0.88), and adjustment for differences in the use of acute medications and invasive procedures partially attenuated this mortality difference (adjusted odds ratio 0.92, 95% confidence interval 0.83 to 1.02). Non-ST-segment elevation acute coronary syndrome patients primarily cared for by a cardiology inpatient service more commonly received evidence-based treatments and had a lower risk of mortality, but these patients had lower-risk clinical characteristics. Results from the present analysis highlight the difficulties with

Minimally invasive versus conventional extracorporeal circulation in minimally invasive cardiac valve surgery.

PubMed

Baumbach, Hardy; Rustenbach, Christian; Michaelsen, Jens; Hipp, Gernot; Pressmar, Markus; Leinweber, Marco; Franke, Ulrich Friedrich Wilhelm

2014-02-01

Minimally invasive extracorporeal circulation (MECC) technology was applied predominantly in coronary surgery. Data regarding the application of MECC in minimally invasive valve surgery are missing largely. Patients undergoing isolated minimally invasive mitral or aortic valve procedures were allocated either to conventional extracorporeal circulation (CECC) group (n = 63) or MECC group (n = 105), and their prospectively generated data were analyzed. Demographic data were comparable between the groups regarding age (CECC vs. MECC: 71.0 ± 7.5 vs. 66.2 ± 10.1 years, p = 0.091) and logistic EuroSCORE I (6.2 ± 2.5 vs. 5.4 ± 3.0, p = 0.707). Hospital mortality was one patient in each group (1.6 vs. 1.0%, p = 0.688). The levels of leukocytes were lower in the MECC group (11.6 ± 3.2 vs. 9.4 ± 4.3 109/L, p = 0.040). Levels of platelets (137.2 ± 45.5 vs. 152.4 ± 50.3 109/L, p = 0.015) and hemoglobin (103.3 ± 11.3 vs. 107.3 ± 14.7 g/L, p = 0.017) were higher in the MECC group. Renal function was better preserved (creatinine: 1.1 ± 0.4 vs. 0.9 ± 0.2 mg/dL, p = 0.019). We were able to validate shorter time of postoperative ventilation (9.5 ± 15.1 vs. 6.3 ± 3.4 h, p = 0.054) as well as significantly shorter intensive care unit (ICU) stay (1.8 ± 1.3 vs. 1.2 ± 1.0 d, p = 0.005) for MECC patients. The course of C-reactive protein did not differ between the groups. We were able to prove the feasibility of MECC even in minimally invasive performed mitral and aortic valve procedures. In addition, the use of MECC provides decreased platelet consumption and less hemodilution. The use of MECC in these selected patients lead to a shorter ventilation time and ICU stay. Georg Thieme Verlag KG Stuttgart · New York.

Impact of availability of hospital-based invasive cardiac services on racial differences in the use of these services.

PubMed

Gregory, P M; Rhoads, G G; Wilson, A C; O'Dowd, K J; Kostis, J B

1999-09-01

Reports indicate that black patients are less likely than white patients to receive invasive cardiac services after hospitalization for acute myocardial infarction (AMI). There is still uncertainty as to why racial differences exist and how they affect patient outcomes. This is the first study to focus on the availability of invasive cardiac services and racial differences in procedure use. Study objectives were to (1) document whether racial differences existed in the use of invasive cardiac procedures, (2) study whether these racial differences were related to availability of hospital-based invasive cardiac services at first admission for AMI, and (3) determine whether there were racial differences in long-term mortality rates. A historical cohort study was conducted with discharge records from all acute care hospitals in New Jersey for 1993 linked to death certificate records for 1993 and 1994. There were 13,690 black and white New Jersey residents hospitalized with primary diagnosis of AMI. Use of cardiac catheterization within 90 days, revascularization within 90 days (percutaneous transluminal coronary angioplasty [PTCA] or coronary artery bypass graft surgery [CABG]), and death within 1 year after admission for AMI were the main outcome measures. Patterns for PTCA and CABG as separate outcomes were also studied. Hospital-based cardiac services available were described as no invasive cardiac services, catheterization only, or PTCA/CABG. To account for payer status and comorbidity differences, patients 65 years and older with Medicare coverage were analyzed separately from those younger than 65 years. Black patients aged 65 and older were generally less likely to receive catheterization and revascularization than white patients, regardless of facilities available at first admission. For patients younger than 65 years, the greatest differences between black and white patients in catheterization and PTCA/CABG use within 90 days after AMI occurred when no

Coronary artery atherosclerosis associated with shift work in chemical plant workers by using coronary CT angiography.

PubMed

Kang, WonYang; Park, Won-Ju; Jang, Keun-Ho; Kim, Soo-Hyeon; Gwon, Do-Hyeong; Lim, Hyeong-Min; Ahn, Ji-Sung; Moon, Jai-Dong

2016-08-01

The aim of this study was to investigate whether shift work is related to elevated risk of coronary artery disease (CAD) by determining the coronary artery calcium (CAC) score and the presence of coronary artery stenosis by using coronary artery CT angiography (CCTA). In this study, 110 male workers participated and underwent a CCTA examination for CAC scoring, which represents coronary artery plaque, and were evaluated for luminal stenosis. All of the participants were working in the same chemical plant, of whom 70 worked day shifts and 40 worked rotating shifts. In a multivariate logistic regression analysis, including age, smoking status, alcohol consumption, regular exercise and waist circumference, shift work was associated with a 2.89-fold increase in the odds of developing coronary plaque compared with day work (OR, 2.89; 95% CI 1.07 to 7.82). The association between shift work and coronary plaque was strong after adjustment for age, low-density lipoprotein cholesterol, hypertension and diabetes mellitus (OR, 2.92; 95% CI 1.02 to 8.33). In addition, the number of years of shift work employment was associated with coronary plaque. However, no association was found between shift work and coronary artery stenosis. Shift work could induce CAD onset via the atherosclerotic process, and shift work employment duration was associated with an increased risk of atherosclerosis in male workers. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Effect of antiischemic therapy on coronary flow reserve and the pressure-maximal coronary flow relationship in anesthetized swine.

PubMed

McFalls, E O; Duncker, D J; Sassen, L M; Gho, B C; Verdouw, P D

1991-12-01

The effect of nifedipine (0.5, 1.0, and 2.0 micrograms/kg/min), metoprolol (0.1, 0.5, and 1.0 mg/kg), the beta 1-selective adrenoceptor partial agonist epanolol (10, 50, and 200 micrograms/kg), or equivalent volumes of isotonic saline (n = 6, in each group), on coronary blood flow capacity were studied in anesthetized swine. Intracoronary bolus injections of adenosine (20 micrograms/kg/0.2 ml) were administered without and during three levels of coronary stenosis, prior to and following each dose of drug, to obtain maximal coronary blood flows at different perfusion pressures in the autoregulatory range. Coronary perfusion pressures were varied by partial inflation of a balloon around the left anterior descending coronary artery. Special care was taken that the stenoses not lead to myocardial ischemia. Three indices of coronary blood flow capacity were used: absolute coronary flow reserve (ACFR, the ratio of maximal to resting coronary blood flow), the slope and the extrapolated pressure at zero flow (Pzf) of the pressure-maximal coronary flow (PMCF) relationship, and relative coronary flow reserve (RCFR, the ratio of maximal coronary blood flow with a stenosis to maximal coronary blood flow without a stenosis) at two of the three levels of stenosis. Nifedipine decreased ACFR from 4.5 +/- 1.9 to 1.9 +/- 0.3 (mean +/- SD; p less than 0.05), reflecting in part the increase in resting coronary blood flow. The nifedipine-induced changes in maximal coronary blood flow were not only due to a drop in perfusion pressure, as the slope of the PMCF relationship decreased from 2.27 +/- 0.49 ml/(min.mm Hg) to 1.54 +/- 0.51 ml/(min.mm Hg) (p less than 0.05), and Pzf decreased from 30 +/- 4 mm Hg to 20 +/- 7 mm Hg (p less than 0.05). Consequently, calculated maximal coronary blood flow was attenuated from 114 +/- 31 ml/min to 93 +/- 37 ml/min at 80 mm Hg, but was enhanced from 23 +/- 13 to 37 +/- 24 ml/min at 40 mm Hg coronary perfusion pressure. In concert with the change in the

Clinical Problems In Coronary Angioscopy

NASA Astrophysics Data System (ADS)

Sherman, C. Todd

1989-06-01

I have been asked to talk about the clinical problems encountered when performing coronary angioscopy. By definition, this discussion will reflect negatively on the procedure. Nevertheless, after presenting some of the data, I hope you will leave thinking optimistically about the future of coronary angioscopy. The first topic that I would like to address, as shown in Figure 1, concerns the goals for coronary angioscopy. What great discoveries might we ekpect from this tool? Is the potential benefit worthy of a large research and development investment? Then, assuming these goals are meritorious, I will compare the difficulties of percutaneous angioscopy with that of a more fully explored technique- intraoperative angioscopy. I will next describe the differences between percutaneous angioscopy of peripheral vasculature, a procedure enjoying more widespread use, and percutaneous coronary angioscopy (a technique less often utilized). I will then outline the basic requirements for any percutaneous coronary angioscopy system whose attributes can resolve some of the inherent challenges of the technique. Even if this hypothetical instrument were developed and proved to be safe and functional, angioscopy will always have intrinsic limitations. I will next outline these shortcomings. This will be followed by a more optimistic topic- a review of the published studies that have utilized percutaneous coronary angioscopy. Finally, I will speculate on developments in coronary angioscopy for the near future.

Increased response of diastolic blood pressure to exercise in patients with coronary artery disease: an index of latent ventricular dysfunction?

PubMed Central

Paraskevaidis, I A; Kremastinos, D T; Kassimatis, A S; Karavolias, G K; Kordosis, G D; Kyriakides, Z S; Toutouzas, P K

1993-01-01

OBJECTIVE--To determine whether an abnormal response of diastolic blood pressure during treadmill exercise stress testing correlated with the number of obstructed vessels and with left ventricular systolic function in patients with coronary artery disease. DESIGN--Diastolic blood pressure was measured invasively during exercise stress testing and coronary angiograms and left ventriculograms were obtained at rest in patients with coronary artery disease. The abnormal (> or = 15 mm Hg) diastolic blood pressure response was compared with the number of obstructed coronary arteries and with left ventricular systolic function. SETTING--Two tertiary referral centres. PATIENTS--50 consecutive patients (mean age 57 years) with coronary artery disease. MAIN OUTCOME MEASURES--The increase in diastolic blood pressure during exercise and its correlation with the appearance and disappearance of ST segment deviation, resting left ventricular systolic function, and the number of obstructed coronary arteries. RESULTS--Group 1: 10 (20%) patients (three with one, four with two, and three with three vessel coronary artery disease) (mean (SD) age 54.7 (12) years) had an abnormal diastolic blood pressure response that appeared 1.2 (0.3) min before ST segment deviation and became normal 0.9 (0.3) min after the ST segment returned to normal. Group 2: 40 (80%) patients (12 with one, 16 with two, and 12 with three vessel coronary arteries disease) (aged 56.8 (8.2) years) had a normal diastolic blood pressure response to stress testing. The ejection fraction (46.3 (5)%) and cardiac index (2.6 (0.1) 1/min/m2) in group 1 were less than in group 2 (61.6 (4.2)% and 3.8 (0.3) 1/min/m2 respectively, p < or = 0.001). The end systolic volume was greater in group 1 than in group 2: 38.7 (0.7 ml/m2 v 28.2 (2.1) ml/m2, p < or = 0.001. CONCLUSION--In patients with coronary artery disease an abnormal increase in diastolic blood pressure during exercise stress testing correlated well with left ventricular

Methamphetamine-associated acute myocardial infarction and cardiogenic shock with normal coronary arteries: refractory global coronary microvascular spasm.

PubMed

Chen, Jack P

2007-04-01

Methamphetamine (MET) is a growing public health concern and is prevalent in, although not limited to, the youth. The drug's association with myocardial infarction is well described and is attributed to accelerated atherosclerosis, hypercoagulable state, and macrovascular epicardial coronary spasm. However, global slow-flow of all coronary systems in the absence of significant stenoses has not been previously reported. We hereby present a young patient who likely experienced severe, global microvascular coronary spasm unrelieved by intracoronary vasodilator therapy, resulting in acute myocardial infarction. The pharmacology of MET, its postulated mechanism in acute coronary syndromes, as well as the pathophysiology and treatments of microvascular coronary spasm are briefly reviewed. Readers are recommended to be vigilant of potential illicit drug use in patients with atypical presentations of acute coronary syndromes.

Distal left circumflex coronary artery flow reserve recorded by transthoracic Doppler echocardiography: a comparison with Doppler-wire

PubMed Central

Auriti, Antonio; Pristipino, Christian; Cianfrocca, Cinzia; Granatelli, Antonino; Guido, Vincenzo; Pelliccia, Francesco; Greco, Salvatore; Richichi, Giuseppe; Santini, Massimo

2007-01-01

Background Coronary flow reserve (CFR) recording by means of transthoracic echocardiography (TTDE) in all the main distal coronary arteries is a challenge for advanced echocardiography. Validation studies of TTDE versus Doppler-wire (DW) recordings are available for Left Anterior Descending artery (LAD) and the Posterior Descending coronary artery (PD), but lacking for the more technically challenging Left Circumflex coronary artery (LCx). Aim To evaluate the reliability of TTDE in assessing CFR in LCx when compared to the intracoronary Doppler flow-wire gold standard. Methods we evaluated 5 patients (age = 60 ± 9 years, 5 males) on LCx by TTDE and invasive CFR assessment. TTDE recording was performed using a low-frequency probe, with a four-chamber as a guiding 2D view. The 2 tests were performed on different days and in random order within 48 hours in a blind fashion. Vasodilator stimulus was adenosine, intravenously (140 γ/kg/min × 3–6 min) for TTDE and intracoronary (40 γ bolus) for DW recordings. Results CFR values on LCx ranged from 1.9 to 2.8 for DW, and from 2.0 to 3.0 for TTDE, with an overall correlation of R = 0,85 (p = 0,06); normal (CFR > 2.5) or abnormal (CFR < 2.5) value was concordantly identified by the 2 techniques in 4 out 5 cases (80%). Conclusion CFR of LCx artery can be obtained noninvasively with TTDE. PMID:17572907

Stress-only myocardial perfusion scintigraphy: a prospective study on the accuracy and observer agreement with quantitative coronary angiography as the gold standard.

PubMed

Ejlersen, June A; May, Ole; Mortensen, Jesper; Nielsen, Gitte L; Lauridsen, Jeppe F; Allan, Johansen

2017-11-01

Patients with normal stress perfusion have an excellent prognosis. Prospective studies on the diagnostic accuracy of stress-only scans with contemporary, independent examinations as gold standards are lacking. A total of 109 patients with typical angina and no previous coronary artery disease underwent a 2-day stress (exercise)/rest, gated, and attenuation-corrected (AC), 99m-technetium-sestamibi perfusion study, followed by invasive coronary angiography. The stress datasets were evaluated twice by four physicians with two different training levels (expert and novice): familiar and unfamiliar with AC. The two experts also made a consensus reading of the integrated stress-rest datasets. The consensus reading and quantitative data from the invasive coronary angiography were applied as reference methods. The sensitivity/specificity were 0.92-1.00/0.73-0.90 (reference: expert consensus reading), 0.93-0.96/0.63-0.82 (reference: ≥1 stenosis>70%), and 0.75-0.88/0.70-0.88 (reference: ≥1 stenosis>50%). The four readers showed a high and fairly equal sensitivity independent of their familiarity with AC. The expert familiar with AC had the highest specificity independent of the reference method. The intraobserver and interobserver agreements on the stress-only readings were good (readers without AC experience) to excellent (readers with AC experience). AC stress-only images yielded a high sensitivity independent of the training level and experience with AC of the nuclear physician, whereas the specificity correlated positively with both. Interobserver and intraobserver agreements tended to be the best for physicians with AC experience.

Cyanotic Congenital Heart Disease The Coronary Arterial Circulation

PubMed Central

Perloff, Joseph K

2012-01-01

Background: The coronary circulation in cyanotic congenital heart disease (CCHD) includes the extramural coronary arteries, basal coronary blood flow, flow reserve, the coronary microcirculation, and coronary atherogenesis. Methods: Coronary arteriograms were analyzed in 59 adults with CCHD. Dilated extramural coronaries were examined histologically in six patients. Basal coronary blood flow was determined with N-13 positron emission tomography in 14 patients and in 10 controls. Hyperemic flow was induced by intravenous dipyridamole pharmacologic stress. Immunostaining against SM alpha-actin permitted microcirculatory morphometric analysis. Non-fasting total cholesterols were retrieved in 279 patients divided into four groups: Group A---143 cyanotic unoperated, Group B---47 rendered acyanotic by reparative surgery, Group C---41 acyanotic unoperated, Group D---48 acyanotic before and after operation. Results: Extramural coronary arteries were mildly or moderately dilated to ectatic in 49/59 angiograms. Histologic examination disclosed loss of medial smooth muscle, increased medial collagen, and duplication of internal elastic lamina. Basal coronary flow was appreciably increased. Hyperemic flow was comparable to controls. Remodeling of the microcirculation was based upon coronary arteriolar length, volume and surface densities. Coronary atherosclerosis was absent in both the arteriograms and the necropsy specimens. Conclusions: Extramural coronary arteries in CCHD dilate in response to endothelial vasodilator substances supplemented by mural attenuation caused by medial abnormalities. Basal coronary flow was appreciably increased, but hyperemic flow was normal. Remodeling of the microcirculation was responsible for preservation of flow reserve. The coronaries were atheroma-free because of the salutory effects of hypocholesterolemia, hypoxemia, upregulated nitric oxide, low platelet counts, and hyperbilirubinrmia. PMID:22845810

Cyanotic congenital heart disease the coronary arterial circulation.

PubMed

Perloff, Joseph K

2012-02-01

The coronary circulation in cyanotic congenital heart disease (CCHD) includes the extramural coronary arteries, basal coronary blood flow, flow reserve, the coronary microcirculation, and coronary atherogenesis. Coronary arteriograms were analyzed in 59 adults with CCHD. Dilated extramural coronaries were examined histologically in six patients. Basal coronary blood flow was determined with N-13 positron emission tomography in 14 patients and in 10 controls. Hyperemic flow was induced by intravenous dipyridamole pharmacologic stress. Immunostaining against SM alpha-actin permitted microcirculatory morphometric analysis. Non-fasting total cholesterols were retrieved in 279 patients divided into four groups: Group A---143 cyanotic unoperated, Group B---47 rendered acyanotic by reparative surgery, Group C---41 acyanotic unoperated, Group D---48 acyanotic before and after operation. Extramural coronary arteries were mildly or moderately dilated to ectatic in 49/59 angiograms. Histologic examination disclosed loss of medial smooth muscle, increased medial collagen, and duplication of internal elastic lamina. Basal coronary flow was appreciably increased. Hyperemic flow was comparable to controls. Remodeling of the microcirculation was based upon coronary arteriolar length, volume and surface densities. Coronary atherosclerosis was absent in both the arteriograms and the necropsy specimens. Extramural coronary arteries in CCHD dilate in response to endothelial vasodilator substances supplemented by mural attenuation caused by medial abnormalities. Basal coronary flow was appreciably increased, but hyperemic flow was normal. Remodeling of the microcirculation was responsible for preservation of flow reserve. The coronaries were atheroma-free because of the salutory effects of hypocholesterolemia, hypoxemia, upregulated nitric oxide, low platelet counts, and hyperbilirubinrmia.