Relation entre la rigidité artérielle et la sévérité du statut coronaire après un syndrome coronaire aigu

BackgroundThe association between arterial stiffness (AS) and stable coronary artery disease (CAD) has been previously demonstrated. Whether increased arterial stiffness is associated with severe CAD in patients with acute coronary syndrome (ACS) is less explored.AimWe aim to investigate the relationship between AS parameters and the extent and severity of CAD in patients with ACS.MethodsThe study population consisted of 275 patients with ACS. We measured various AS parameters including pulse wave velocity (PWV), augmentation index (AIx), and central pulse pressure (cPP). CAD extent and severity was evaluated by the number of vessels with greater than 70% stenosis.ResultsThe study population was predominantly men (77, 5%) with an average age of 56, 4 ± 10, 6 years. One hundred and fifteen patients were diabetic and 97 were hypertensive. One hundred fifty patients were admitted for ST elevation myocardial infarction (54, 5%) and 37, 5% for non ST elevation myocardial infarction. Thirty six percent of patients had single vessel disease and 47, 6% of the study population had multivessel disease. At the multivariate analysis, a positive correlation was observed between the number of coronary vessels disease and PWV. PWV (OR = 1,272; IC95% [1,090; 1,483]; p = 0,002) and cPP (OR = 1,071; IC95% [1,024; 1,121]; p = 0,003) were also independent predictors of multivessel disease.ConclusionIn patient with ACS, PWV is correlated with the extent of coronary artery disease, as measured by the number of vessels disease. PWV and cPP were also independent predictors of multivessel disease.     

Matrix metalloproteinase-9 (MMP9) and high sensitivity C – Reactive protein (hs-CRP) in coronary artery ectasia

ObjectiveThe specific causative mechanisms of abnormal luminar dilatation in coronary artery ectasia (CAE) are essentially unknown. Destruction of the extracellular matrix may be responsible for ectasia formation. Thus, we investigated the role of matrix metalloproteinases (MMP9), and inflammatory marker (high-sensitive C-reactive protein) in CAE patients.MethodsThis study consisted of 30 consecutive CAE patients, 30 obstructive coronary artery disease (CAD) patients, and 20 controls with normal coronary arteries undergoing cardiac catheterization. Plasma levels of MMP-9, and hs-CRP were measured.ResultsHs-CRP level was significantly higher in the the CAE group than both in the CAD and control groups (2.3 ± 0.5, 1.19 ± 0.54, 0.8 ± 0.3 mg/l, respectively, both p < 0.001), while, MMP-9 level was significantly higher in both CAE group and CAD than control groups (27.71 ± 4.7, 25.2 ± 4.1, 18.6 ± 3.3 ng/ml, respectively , both p < 0.001). In subgroup analyses, MMP-9 level was significantly higher in CAE patients with multivessel involvement compared to those with single-vessel ectasia (29.4 ± 3.1 vs. 25.2 ± 5.5 ng/ml, P = 0.01), while hs CRP level was comparable in both groups (2.3 ± 0.52 vs. 2.4 ± 0.45 ng/ml, P = 0.82).ConclusionOur results suggest that the increased levels of MMP-9, hs-CRP may be responsible for ectasia formation in patients with CAE and plasma level of MMP-9 is correlated with the severity of CAE.     

Increased expression of markers of early atherosclerosis in patients with inflammatory bowel disease

Background & AimsRecent studies documented an increased cardiovascular risk in patients with inflammatory bowel disease (IBD). Our study aimed at investigating the prevalence of intima-media thickness (IMT) of the carotid arteries and the arterial stiffness indices as markers of early atherosclerosis in young IBD patients.MethodsWe recruited 68 consecutive IBD patients, and 38 matched healthy controls less than 45 years old (median age 31.6 ± 8.1 years). Clinical and demographic features, cardiovascular risk factors, history of cardiovascular events, concomitant therapies were registered on a dedicate database. Carotid IMT was evaluated by using high resolution B-mode ultrasonography. Arterial stiffness was assessed by measurement of carotid-femoral Pulse Wave Velocity (PWV) and Augmentation Index (AIx).ResultsTotal cholesterol (P < 0.013) and LDL-cholesterol (P < 0.019) levels were significantly lower in IBD patients compared to controls. Carotid IMT was higher in IBD than in controls (P < 0.047), but there was no statistically significant difference among Crohn's Disease (CD) and Ulcerative Colitis (UC) patients. Moreover, PWV and AIx were significantly higher in patients as compared to controls (P < 0.006 and P < 0.004 respectively). No medication seemed to affect vascular measurements, though stiffness parameters were significantly higher in patients treated with 5-ASA (11.9 (9.7) vs 18.2 (10.2), P < 0.021), suggesting a lack of efficacy of 5-ASA in protecting IBD patients from early atherogenesis.ConclusionsYoung IBD patients show an increase in subclinical markers of atherosclerosis. Future studies need to address whether these markers result in an increased risk of cardiovascular events in these patient.     

Independent relationship of serum uric acid levels with leukocytes and coronary atherosclerotic burden

Background and AimEpidemiological studies have shown that increased serum uric acid (SUA) level is associated with coronary artery disease (CAD). Leukocytes have been shown to play an important role in the atherosclerotic process. The aim of the study was to investigate whether there is any relationship among SUA, leukocyte counts and coronary atherosclerotic burden in patients who are suspected of having CAD.Method and resultsWe enrolled 690 eligible patients who had undergone coronary angiography between October 2005 and June 2006 in a consecutive manner. The relationship of SUA with total and differential leukocyte counts and CAD was investigated. Serum uric acid levels (5.57 ± 1.64 vs 4.63 ± 1.27 mg/dl, p < 0.001) and leukocytes were higher in patients with CAD than those with normal coronary arteries (NCA). When we divided the patients into four groups according to the quartiles of SUA, we found that the monocyte count was prominently related with SUA (478 ± 165, 553 ± 177, 565 ± 199 and 607 ± 229 mm⁻³, Q1–Q4, p < 0.001). In multivariate analysis, SUA was an independent predictor of CAD (OR, 1.270; 95% CI, 1.087–1.484, p = 0.003). When we performed multiple linear regression analyses to determine the independent predictors of inflammatory cells in blood, we found a strong, positive and independent relationship between SUA with neutrophils (β ± SE: 206 ± 60, p = 0.001) and monocytes (β ± SE: 35 ± 7, p < 0.001).ConclusionOur study results demonstrated that neutrophils and monocytes which play an important role in inflammation and atherosclerosis were independently related with SUA. This finding suggests an important epidemiologic relation and may provide a possible causative mechanism of SUA in atherosclerotic process.     

Early detection of premature subclinical coronary atherosclerosis in systemic lupus erythematosus patients

ObjectiveTo elucidate early coronary atherosclerotic changes in premenopausal systemic lupus erythematosus (SLE) female patients without clinical cardiovascular manifestation using a 64-slice Multi-detector computed tomography (MDCT) scan to detect coronary calcification and measure coronary calcium score (CCS), and to find out its correlation to some traditional and non-traditional risk factors.MethodologySixty consecutive premenopausal SLE female patients, and sixty age and sex matched healthy subjects without known systemic, immunological, or cardiovascular disease (served as a control group) underwent clinical examination, serological analysis, and 64-slice MDCT-based coronary calcium scoring. All the clinical, serological, and MDCT parameters of the patients were correlated.ResultsCoronary calcification (CC) was seen in 21 patients (35%), the number of atherosclerotic calcified plaques ranged from 0 to 19. Calcium scores ranged from 0 to 843. In contrast to control subjects, SLE patients had significantly higher erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), total cholesterol level, low-density lipoprotein (LDL), immunoglobulin G (IgG) and IgM anti-cardiolipin antibodies, serum intracellular adhesion molecule (sICAM) and E-selectin levels. SLE patients had highly significantly more atherosclerotic plaques (3 ± 0.66 compared to 0.1 ± 0.07, p < 0.001) and higher CCS (59.2 ± 20.3 compared to 2.6 ± 1.85, p < 0.001). Significant positive correlation was found between both number of atherosclerotic plaques and CCS and total cholesterol level, LDL, cumulative prednisone dose, SLE disease activity index (SLEDAI), ESR, CRP, sICAM-1, E-Selectin, and anti-cardiolipin antibodies (p < 0.05 in all).ConclusionPre-menopausal SLE female patients free from clinical atherosclerotic vascular disease have an increased number of atherosclerotic plaques and CCS, which correlate positively with SLEDAI disease activity score, serum CRP, anticardiolipin antibodies, sICAM-1, E-Selectin, LDL level, total cholesterol level, and cumulative prednisone dose. In addition, we conclude that MDCT is a non-invasive, sensitive, reproducible, and reliable tool for accurate measurement of coronary calcification.     

Impact of coronary artery calcification on percutaneous coronary intervention and postprocedural complications

BackgroundExcessive coronary calcification can lead to adverse outcomes after percutaneous coronary intervention (PCI). We therefore evaluated the impact of coronary calcium score (CCS) measured by multidetector computed tomography (MDCT) on immediate complications of PCI and rate of restenosis.MethodsWe performed a single-center retrospective analysis of 84 patients with coronary stenosis diagnosed by MDCT who underwent PCI. The Agatston method was used to measure total, target-vessel, and segmental (stent deployment site) CCS.ResultsIn 108 PCI procedures, 32 lesions (29.5%) were American College of Cardiology/American Heart Association type A, 60 (55.5%) were type B, and 16 (15%) were type C. ANOVA showed significantly higher segmental CCS in type C than in type A lesions (29 ± 51 vs. 214 ± 162; p = 0.03). Six patients (7.1%) had periprocedural complications and seven (8.3%) had in-stent restenosis and angina. Mean total, target-vessel, and segmental CCS was significantly higher in complicated than in successful PCI (199 ± 325 vs. 816 ± 624, p = 0.001; 92 ± 207 vs. 337 ± 157, p = 0.001; and 79 ± 158 vs. 256 ± 142, p = 0.003, respectively), but there was no significant difference in CCS between successful PCI and PCI complicated by late restenosis.ConclusionsCCS measured by MDCT has an important role in predicting early, but not late, complications from PCI.     

P-wave voltage and peaking on electrocardiogram in patients undergoing head-up tilt testing for history of syncope

BackgroundOnly scanty data are available in the literature on P-wave (PW) morphology at ECG in patients with history of vasovagal syncope undergoing diagnostic functional testing. In this study, we evaluated resting and head-up tilt testing (HUTT) related changes in PW voltage (PWV) and duration (PVD) and their relationship with triggered syncope.Methods55 patients, mean aged 41 ± 19y (35 F), without patent heart disease or neuropathy, underwent potentiated HUTT according to the Italian protocol. Heart rate (HR), blood pressure (BP), PR-interval, PWV and PWD were measured at rest, 15 min from passive position (15-min) and after nitroglycerine (peak-HR). PW peaking (PWP) was calculated as percent increase in PWV than baseline values. Patients were divided into 2 groups based on tilt-positive (group-A) or negative (group-B) response.Results20 patients (36%) entered the group-A, whereas 35 (64%) the group-B. Higher PWV was observed at baseline in group-A (0.147 ± 0.034 mV vs 0.114 ± 0.036 mV in group-B, p = 0.001), with no differences in the remaining ECG measurements. BP was lower in group-A than in B, both at 15-min and peak-HR. HUTT-related PWP in lead II (the most significant among all inferior leads) was 31 ± 30% in group-A vs 95 ± 54% in group-B (p < 0.0001) at 15-min, and 52 ± 44% vs 112 ± 72% at peak-HR, respectively (p = 0.002). 75% of patients with PWP ≤ 50% experienced HUTT-triggered syncope, vs 5% of those with PWP ≥ 100% (p < 0.0001).ConclusionsThis study shows a potential relationship between HUTT-triggered syncope and low or absent PWP, suggesting a role for atrial chamber functional involvement in the mechanisms underlying the vasovagal syncope.     

Distribution,frequency and clinical implications of napkin-ring sign assessed by multidetector computed tomography

BackgroundPlaque rupture and secondary thrombus formation play key roles in the onset of acute coronary syndrome (ACS). Plaques showing the napkin-ring sign in multidetector computed tomography (MDCT) have been reported as thin-cap fibroatheroma that is recognized as a precursor lesion for plaque rupture. The purpose of this study was to investigate distribution and frequency of napkin-ring sign and its relationship to features indicating coronary plaque vulnerability on MDCT in patients with coronary artery disease.MethodsWe enrolled 273 patients with ACS (n = 61) or stable angina pectoris (SAP, n = 212) who were assessed by MDCT. The definition of the napkin-ring sign was the presence of a ring of high attenuation and the CT attenuation of a ring presenting higher than those of the adjacent plaque and no greater than 130 HU.ResultsThe culprit plaques with the napkin-ring sign show higher remodeling index and lower CT attenuation (1.15 ± 0.12 vs. 1.02 ± 0.12, p < 0.01 and 39.9 ± 22.8 vs. 72.7 ± 26.6, p < 0.01, respectively). Napkin-ring sign at culprit lesions was more frequent in patients with ACS than those with SAP (49.0% vs. 11.2%, p < 0.01). Moreover, napkin-ring sign at non-culprit lesions was more frequently observed in ACS patients compared with SAP patients (12.7% vs. 2.8%, p < 0.01). The distribution of the napkin-ring sign in the right coronary arteries and left circumflex arteries of our population was relatively even, whereas the napkin-ring sign in the left anterior descending artery was common in the proximal sites (p < 0.01).ConclusionsThe napkin-ring sign assessed by MDCT represents similar clinical features of fibroatheroma. MDCT could contribute to the search for fibroatheroma.     

The incremental role of obstructive sleep apnoea on markers of atherosclerosis in patients with metabolic syndrome

ObjectiveMetabolic syndrome (MS) is associated with subclinical atherosclerosis, but the relative role of obstructive sleep apnoea (OSA) is largely unknown. The main objective of this study is to determine the impact of OSA on markers of atherosclerosis in patients with MS.MethodsEighty-one consecutive patients with MS according to the Adult Treatment Panel III underwent a clinical evaluation, polysomnography, laboratory and vascular measurements of carotid intima media thickness (IMT), carotid-femoral pulse wave velocity (PWV) and carotid diameter (CD) in a blind fashion. OSA was defined as an apnoea-hypopnoea index (AHI) ≥15 events/hour. Multiple linear regression was performed to determine the variables that were independently associated with the vascular parameters.ResultsFifty-one patients (63%) had OSA. No significant differences existed in age, sex, MS criteria, and cholesterol levels between patients with (MS+OSA) and without OSA (MS?OSA). Compared with MS?OSA patients, MS+OSA patients had higher levels of IMT (661 ± 117 vs. 767 ± 140 μm), PWV (9.6 ± 1.0 vs. 10.6 ± 1.6 m/s), and CD (6705 ± 744 vs. 7811 ± 862 μm) (P < 0.001 for each comparison). Among patients with MS+OSA, all vascular parameters were similar in patients with and without daytime sleepiness. The independent parameters associated with IMT, PWV, and CD were AHI, abdominal circumference, and systolic blood pressure (R² = 0.42); AHI and systolic blood pressure (R² = 0.38); and AHI, age, abdominal circumference and systolic blood pressure (R² = 0.45), respectively. The R² of AHI for IMT, PWV and CD was 0.12, 0.10 and 0.20, respectively.ConclusionsOSA is very common and has an incremental role in atherosclerotic burden in consecutive patients with MS.     

Plateletcrit and red cell distribution width are independent predictors of the slow coronary flow phenomenon

Background and purposeEndothelial dysfunction may play a role in the pathogenesis of the slow coronary flow (SCF) phenomenon. A detailed examination of blood cellular components has not been performed for this condition. We investigated the relationship between SCF and whole blood cell counts.MethodRecords of 17,315 patients who underwent coronary angiography between January 2006 and December 2012 were evaluated retrospectively. A total of 146 patients with SCF were compared with 148 patients with normal coronary arteries according to demographic data, complete blood count, and biochemical parameters.ResultsThe following parameters were significantly higher in SCF patients than in patients with normal coronary arteries: percentage of smokers (36.3% vs. 25%, p = 0.036), body mass index (26.69 ± 2.84 vs. 26.07 ± 3.15, p = 0.049), white blood cells (WBCs) (7.52 ± 1.43 × 10³ mm^–3 vs. 7.01 ± 1.42 × 10³ mm^–3, p = 0.002), red cell distribution width (RDW) (13.68 ± 1.42% vs. 13.15 ± 1.13%, p < 0.001), platelets (250.29 ± 50.96 × 10³ mm^–3 vs. 226.10 ± 38.02 × 10³ mm^–3, p < 0.001), plateletcrit (PCT) (0.214 ± 0.40% vs. 0.184 ± 0.29%, p < 0.001), mean platelet volume (8.63 ± 1.10 fL vs. 8.22 ± 0.83 fL, p < 0.001), platelet distribution width (PDW) (16.58 ± 0.76% vs. 16.45 ± 0.57%, p = 0.028), and neutrophils (4.44 ± 1.25 × 10³ mm^–3 vs. 4.12 ± 1.24 × 10³ mm^–3, p = 0.029). Positive PCT values [odds ratio (OR), 4.165; 95% confidence interval (CI), 2.493–6.959; p < 0.001) and RDW (OR, 1.304; 95% CI, 1.034–1.645; p = 0.025) were independent predictors of SCF.ConclusionAlthough within the normal range, the increased numbers of WBCs and neutrophils in patients with SCF suggest that SCF may be a subclinical inflammatory condition. Furthermore, increased RDW and PDW in SCF patients may cause microvascular blood flow resistance due to impaired cell deformability. The PCT provides reliable data regarding total platelet mass and may be a useful predictor of SCF.     

Relationship between arterial stiffness parameters and the extent and severity of coronary artery disease

BackgroundThe association between arterial stiffness (AS) and coronary artery disease (CAD) has been previously demonstrated. In the present study, we aim to investigate the relationship between various AS parameters and the extent and severity of CAD.MethodsThe study population consisted of 411 patients with CAD documented by coronary angiography. We measured various AS parameters including augmentation index (AIx), augmentation pressure (AP), pulse wave velocity (PWV), central systolic pressure (cSys), central diastolic pressure (cDia) and central pulse pressure (cPP) with pulse wave analysis. Angiographic images were used to calculate Gensini score and Syntax score. AS parameters were compared using Gensini score and Syntax score.ResultsSyntax score is correlated with age, cSys, cPP, PWV, AP, brachial pulse pressure (bPP), hemoglobin, urea, diabetes mellitus, left main coronary artery disease (p < 0.10 for each). However, Gensini score is correlated only with age, diabetes mellitus, left main coronary artery disease and bPP (p < 0.10 for each). Multivariate analysis revealed age, diabetes mellitus, left main coronary artery disease and bPP as significant predictors of Syntax score; however, for Gensini score, age, diabetes mellitus, gender, left main coronary artery disease, and bPP are determined as predictors.ConclusionAS parameters are not associated with Syntax score or Gensini score. Apart from traditional risk factors, bPP appears to be the only significant predictor for Syntax score and Gensini score.     

Coronary artery diseases in Japanese patients with nonvalvular atrial fibrillation

BackgroundBoth the prevalence of atrial fibrillation and coronary artery disease (CAD) is increasing in aged societies. However, limited data are available regarding the prevalence of CAD and the incidence of coronary events in Japanese patients with nonvalvular atrial fibrillation (NVAF).Methods and resultsThe data in this study were derived from Shinken Database 2004–2010, which includes 15,227 new patient visitors to the Cardiovascular Institute between June 2004 and March 2011. In the database, 1835 patients were diagnosed with NVAF (mean age 63 years, mean CHADS2 score 1.1 ± 1.1, and 75% were men). The prevalence of CAD at the initial visit was 118 patients (6.4%). They were older age and had a greater prevalence of men, more history of congestive heart failure and more history of cardiovascular risk factors rather than those without. During the follow-up period of 532 ± 599 days, coronary events (myocardial infarction, unstable angina, and stable angina) occurred in 51 patients (1.9%/year). Multivariate analysis showed that a history of CAD (p < 0.001) and older age (p = 0.024) were independent predictors of the incidence of future coronary events.ConclusionsIn Japanese patients with NVAF, both the presence of CAD and the occurrence of coronary events are not uncommon. History of CAD and older age are strongly associated with the incidence of coronary events.     

Outcome of coronary angiography and percutaneous coronary intervention in Egyptian women with chronic stable angina

BackgroundA suboptimal degree of attention has focused on the detection and management of coronary artery disease (CAD) in women until recently. We sought out to study the anatomy of coronary arteries in women by the means of coronary angiography in comparison to men. The results of percutaneous coronary intervention (PCI) and in hospital outcomes were studied and compared to men.MethodsThe study included 488 female and 492 male patients with chronic stable angina undergoing coronary angiography ± PCI taken consecutively. The angiographic results, interventional details and procedural success, and related complications were collected and statistically analyzed.ResultsFemale patients had similar coronary risk factors with higher incidence of diabetes mellitus and lower history of smoking. The likelihood of non-atherosclerotic affliction of the coronaries was 47% in women vs. 25.5% in men (P < 0.001). The prevalence of multivessel affliction and more complex lesions were significantly lower in the female patients compared to their male counterparts (P < 0.001). Female patients had lower rate of PCI procedures and lower number of stents implanted (P < 0.001) including drug eluting stents. The success rates were similar in both the sexes, with relatively higher complication rate in the female group.ConclusionEgyptian women have generally similar risk profile to male patients with CAD and tend to receive less aggressive therapy. They showed less severe coronary atherosclerosis than men and potentially have lower PCI procedures with similar acute success rates and relatively higher procedure-related complications.     

Association of prediabetes with diffuse coronary narrowing and small-vessel disease

BackgroundA significant number of patients may not benefit from conventional techniques of myocardial revascularization due to diffuse coronary artery disease (CAD) or small coronary arterial sizes because of smaller arteries causing anastomotic technical difficulties and poor run-off. Diabetic patients have a more severe and diffuse coronary atherosclerosis with smaller coronary arteries limiting the possibility to perform a successful and complete revascularization, but this has not been examined in prediabetics.ObjectiveTo evaluate whether there is an association between prediabetes and the coronary arterial size.MethodsWe prospectively studied 168 consecutive patients with CAD and 172 patients with normal coronary artery anatomy (NCA). Patients were divided into three groups according to hemoglobin (Hb) A1c levels as “normal,” “prediabetic,” and “diabetic” groups, and the coronary artery sizes and Gensini scores were analyzed.ResultsThere were 78 female patients and 90 male patients in the CAD group, and 87 female patients and 85 male patients in the NCA group. There was a statistically significant difference in distal and proximal total coronary arterial size among the CAD and NCA groups for both genders. There was a positive correlation between the HbA1c subgroups and Gensini score (Spearman's ρ: 0.489, p < 0.001 in female group; Spearman's ρ: 0.252 p = 0.016 in male group).ConclusionWe found that prediabetic patients have a smaller coronary size and diffuse coronary narrowing for both genders, particularly in distal coronary arterial tree of left anterior descending coronary artery. The early detection of prediabetes in daily cardiology practice may provide more appropriate coronary lesion for percutaneous or surgical revascularization.     

The effect of percutaneous coronary revascularization on plasma N-terminal pro-B-type natriuretic peptide levels in stable coronary artery disease

BackgroundThis study was conducted to assess the effect of percutaneous coronary revascularization (PCR) on plasma NT-proBNP concentration in patients with chronic stable angina (CSA).MethodsThis prospective open label interventional study included 22 patients with moderate to severe CSA, normal left ventricular (LV) systolic functions and critical (>90%) proximal stenosis in one of the three major epicardial coronary arteries. After stabilization of medications for 8 weeks, resting supine plasma NT-proBNP levels were measured and patients underwent PCR of the involved vessels. Eight weeks later, with medications unaltered; plasma NT-proBNP levels were repeated and compared with the baseline levels. LV systolic and diastolic functions were assessed before and after PCR.ResultsThe mean age of the patients was 61.27 ± 8.87 years. Out of 22 patients, 20 were male and 2 were female. PCR was performed on left anterior descending coronary artery (LAD) in 12 patients and in a non-LAD vessel in 10 patients. After 8 weeks of successful PCR, there was a significant overall reduction in mean plasma NT-proBNP levels (from 244.36 ± 218.99 to 168.68 ± 161.61 pg/mL, p = 0.016). The patients who underwent PCR of LAD demonstrated significantly reduced NT-pro-BNP levels after PCR (p = 0.009). In the non-LAD group, NT-proBNP levels also decreased, albeit insignificantly (p = 0.432). Reduction in NT-proBNP was independent of change in LV systolic functions.ConclusionSuccessful PCR, by relieving myocardial ischemia, significantly reduced plasma NT-proBNP levels in majority of the patients with chronic stable angina secondary to critical epicardial coronary artery stenosis.     

Trends in the treatment and outcomes of elderly patients with acute coronary syndrome: Results from the CZECH registries

BackgroundThe number of elderly patients in the population is rapidly increasing, and little is known about how adherence to recommended treatment strategies in elderly patients with acute coronary syndrome (ACS) has changed over time.AimTo analyze trends in the treatment and outcomes of elderly patients with ACS from two registries conducted in the Czech Republic over 10 years.Methods and resultsData from the CZECH-1 and CZECH-3 registries were used in this study. These registries collected data in autumn 2005 and autumn 2015, and contain data from 1952 and 1754 unselected patients, respectively. All patients had been hospitalized with an initial diagnosis of ACS. There were 490 (25.7%) elderly patients in the CZECH-1 registry and 484 (28.1%) elderly patients in the CZECH-3 registry (p = 0.045) with an average age of 80.6 ± 4 and 82.1 ± 5 years (p < 0.001), respectively. ACS was confirmed in 345 (72%) and 352 (73.6%) elderly patients (p = 0.781), respectively. There was higher use of percutaneous coronary intervention (65.2% and 54.8%; p < 0.001), dual antiplatelet treatment, ACE inhibitors, and statins during treatment in the CZECH-3 compared to the CZECH-1 registry. No differences in hospital mortality of elderly patients with confirmed ACS were observed between registries (8.2% vs. 10.4%; p = 0.790).ConclusionThe proportion of patients with ACS that are elderly is increasing along with their increasing average age. Adherence to guideline-recommended therapy in this subgroup of patients has improved over time, but hospital mortality remains unchanged.     

Paraoxonase 1 gene (Gln192–Arg) polymorphism and the risk of coronary artery disease in type 2 diabetes mellitus

BackgroundParaoxonase 1 (PON1) is reported to have antioxidant and cardioprotective properties. Recently, an association of glutamine (Gln) or type A/arginine (Arg) or type B polymorphism at position 192 of PON1 gene has been suggested with coronary artery disease (CAD) among patients with diabetes mellitus (DM). However, conflicting results have also been reported.ObjectivesTo investigate the relationship between PON1 gene (Gln¹⁹²–Arg) polymorphism and the presence, extent and severity of CAD in type 2 DM.MethodsThe study comprised 180 patients recruited from those undergoing coronary angiography for suspected CAD, who were divided according to the presence or absence of CAD and DM into four groups: Group I (n = 40 patients) nondiabetic subjects without CAD, Group II (n = 45 patients) diabetic patients without CAD, Group III (n = 47 patients) nondiabetic patients with CAD and Group IV (n = 48 patients) diabetic patients with CAD. PON1(Gln¹⁹²–Arg) genotype was assessed using polymerase chain reaction (PCR) followed by AlwI digestion.ResultsThe frequency of Gln allele (type A) was significantly higher in Group I and Group II compared to Group III and Group IV (62.5%, 60% vs. 38.3%, 31.25%, respectively, p < 0.001) while the frequency of Arg allele (type B + type AB) was significantly higher in ischemic groups (III and IV) compared to nonischemic groups (I and II) (61.7%, 68.75% vs. 37.5%, 40%, respectively, p < 0.001). Patients with CAD and DM (Group IV) have significantly higher severity score and vessel score than those with CAD only (Group III) (9.7 ± 2.97, 2.44 ± 0.56 vs. 6.99 ± 3.71, 1.67 ± 0.89, respectively, p < 0.001) Patients with vessel score 3 had significantly higher severity score and higher Arg allele frequency than patients with vessel score 2, the latter group had also significantly higher severity score and Arg allele frequency than patients with vessel score 1 (8.9 ± 2.79 vs. 5.21 ± 2.13 and 80.49% vs. 67.86%), (5.21 ± 2.13 vs. 3.11 ± 0.89 and 67.86% vs. 53.85%), p < 0.001 for all. In multivariate logistic regression analysis of different variables for prediction of CAD, age [OR 2.99, CI (1.11–10.5), p < 0.01], smoking [OR 4.13, CI (1.37–11.7), p < 0.001], low-density lipoprotein (LDL) cholesterol > 100 mg/dL [OR 4.31, CI (1.25–12.5), p < 0.001], high-density lipoprotein (HDL) cholesterol < 40 mg/dL [OR 5.11, CI (1.79–16.33), p < 0.001] and PON1 192 Arg allele [OR 4.62, CI (1.67–13.57), p < 0.001] were significantly independent predictors of CAD.ConclusionArg allele of PON1 192 gene polymorphism is an independent risk factor for CAD and is associated not only with the presence of CAD but also with its extent and severity and its impact is clearly more pronounced in diabetic patients.     

Troponin levels in patients with stable CAD

IntroductionCardiac troponins are known as specific markers of myocardial damage. Their elevation in the serum is not always related to acute myocardial ischaemia. The increased sensitivity of diagnostic kits has resulted in an increase in the number of positive results in patients without acute coronary syndrome (ACS).Study objectivesTo determine the level of highly sensitive troponin T (hs TnT) in stable patients (without ACS) before selective coronarography (SCG) and to determine the correlation between hs TnT values and the extent of atherosclerotic damage to the coronary arteries.MethodologyWe studied a group of 251 consecutive patients with indications for SCG diagnosis. Indication criteria were stable angina pectoris, shortness of breath, newly diagnosed heart failure, syncope, and ventricular arrhythmia. Exclusion criteria were acute coronary syndrome, including unstable angina pectoris, prior cardiopulmonary resuscitation, cerebrovascular accident (CVA) within the last 6 months, and ongoing sepsis. The hs TnT value was determined before SCG (normal range, 0–0.013 μg/l). Monitored parameters included coronary angiography (70% stenosis of coronary artery diameter was considered significant coronary disease), age, gender, heart rate, and serum creatinine levels. The study included 182 patients with normal renal function and 69 patients with renal insufficiency. The results were processed using STATISTICA (version 12), StatSoft©, Inc. (2013).ResultsThe average age of the studied population was 69.6 ± 10.3 years (median, 70 years); 33% of patients were women. The serum level of hs TnT for the entire population was 0.031 ± 0.091 μg/l (0.014). A positive hs TnT was noted in 133 patients. The population study group consisted of 121 patients with normal coronary arteries or with insignificant atherosclerotic disease. Significant damage involving one or more arteries was present in 130 patients. In the subgroup with significant coronary disease, we found a significantly higher hs TnT level than in the group of patients without significant coronary disease: 0.043 ± 0.125 μg/l (0.018) vs. 0.019 ± 0.018 μg/l (0.013) (p = 0.008) (Mann–Whitney test).Significantly higher troponin levels were found in the group of patients with renal insufficiency than in the subgroup with normal creatinine levels: 0.057 ± 0.150 μg/l (0.023) vs. 0.022 ± 0.053 μg/l (0.012), respectively (p < 0.05) (Mann–Whitney test).ConclusionSlightly elevated serum troponin T levels are common in patients with stable coronary artery disease (CAD). We observed a significant correlation between the level of troponin and the presence of atherosclerotic damage to the coronary arteries. A significant correlation between the value of troponin and the extent of atherosclerotic damage (in terms of the number of damaged arteries) could not be demonstrated. On the basis of our findings, the absolute level of troponin T in patients with stable CAD must be interpreted with caution, especially in patients who also have renal insufficiency. Determination of basal troponin T levels in patients with stable CAD is reasonable as they may be used for comparison in case of change in a patient's clinical condition.     

The role of epicardial adipose tissue in coronary artery disease in non-obese patients

BackgroundEpicardial adipose tissue (EAT) surrounding the heart may contribute to the development of coronary artery disease (CAD) through its local secretion of adipocytokines. Although the quantity of EAT is associated with obesity and metabolic syndrome, the role of EAT in the development of CAD in non-obese patients remains to be determined.MethodsThis study included 41 patients with CAD who underwent coronary artery bypass graft surgery and 28 patients without CAD who underwent other cardiac surgery. EAT volume was measured by 64-slice multi-detector computed tomography before the surgery. We obtained pericardial fluid and epicardial and subcutaneous adipose tissue samples at the surgery. We investigated the relationship between EAT volume and adiponectin levels in pericardial fluid and incident CAD in patients with and without obesity (body mass index > 25 kg/m²).ResultsThere was no significant difference in EAT volume between obese patients with and without CAD (55.5 ± 40.2 mL vs. 40.1 ± 19.7 mL, p = 0.323). However, EAT volume was significantly greater in non-obese patients with CAD compared to those without CAD (35.0 ± 18.8 mL vs. 15.7 ± 11.0 mL, p < 0.001). Adiponectin concentrations in pericardial fluid were significantly lower in non-obese patients with CAD compared to those without CAD (2.7 ± 2.0 μg/mL vs. 4.3 ± 3.7 μg/mL, p = 0.049), whereas the adiponectin levels were decreased in obese patients regardless of the presence of CAD. Non-obese patients with CAD had significantly larger size adipocytes in EAT but not subcutaneous adipose tissue compared to those without CAD. Multiple logistic regression analysis showed that increased EAT volume was independently associated with incident CAD in non-obese patients.ConclusionIncreased EAT may play a crucial role in development of CAD through impairment of adiponectin secretion in non-obese patients.     

Comentário a «Será que a diferença na opacificação coronária corrigida medida por TC é preditora do fluxo coronário?»

ObjectivesA proof-of-concept study was undertaken to determine whether differences in corrected coronary opacification (CCO) within coronary lumen can identify arteries with abnormal resting coronary flow.BackgroundAlthough computed tomographic coronary angiography can be used for the detection of obstructive coronary artery disease, it cannot reliably differentiate between anatomical and functional stenoses.MethodsComputed tomographic coronary angiography patients (without history of revascularization, cardiac transplantation, and congenital heart disease) who underwent invasive coronary angiography were enrolled. Attenuation values of coronary lumen were measured before and after stenoses and normalized to the aorta. Changes in CCO were calculated, and CCO differences were compared with severity of coronary stenosis and Thrombolysis In Myocardial Infarction (TIMI) flow at the time of invasive coronary angiography.ResultsOne hundred four coronary arteries (n = 52, mean age = 60.0 ± 9.5 years; men = 71.2%) were assessed. Compared with normal arteries, the CCO differences were greater in arteries with computed tomographic coronary angiography diameter stenoses ≥50%. Similarly, CCO differences were greater in arteries with TIMI flow grade <3 (0.406 ± 0.226) compared with those with normal flow (TIMI flow grade 3) (0.078 ± 0.078, p < 0.001). With CCO differences, abnormal coronary flow (TIMI flow grade < 3) was identified with a sensitivity and specificity, positive predictive value, and negative predictive value of 83.3% (95% confidence interval [CI]: 57.7 to 95.6%), 91.2% (95% CI: 75.2% to 97.7%), 83.3% (95% CI: 57.7% to 95.6%), and 91.2% (95% CI: 75.2% to 97.7%), respectively. Accuracy of this method was 88.5% with very good agreement (kappa = 0.75, 95% CI: 0.55 to 0.94).ConclusionsChanges in CCO across coronary stenoses seem to predict abnormal (TIMI flow grade < 3) resting coronary blood flow. Further studies are needed to understand its incremental diagnostic value and its potential to measure stress coronary blood flow.