Search

Spontaneous coronary artery dissection (SCAD) is an increasingly diagnosed cause of myocardial infarction with unclear pathophysiology. The aim of the study was to test if vascular segments site of SCAD present distinctive local anatomy and hemodynamic profiles. Coronary arteries with spontaneously healed SCAD (confirmed by follow-up angiography) underwent three-dimensional reconstruction, morphometric analysis with definition of vessel local curvature and torsion, and computational fluid dynamics (CFD) simulations with derivation of time-averaged wall shear stress (TAWSS) and topological shear variation index (TSVI). The (reconstructed) healed proximal SCAD segment was visually inspected for co-localization with curvature, torsion, and CFD-derived quantities hot spots. Thirteen vessels with healed SCAD underwent the morpho-functional analysis. Median time between baseline and follow-up coronary angiograms was 57 (interquartile range [IQR] 45–95) days. In seven cases (53.8%), SCAD was classified as type 2b and occurred in the left anterior descending artery or near a bifurcation. In all cases (100%), at least one hot spot co-localized within the healed proximal SCAD segment, in 9 cases (69.2%) ≥ 3 hot spots were identified. Healed SCAD in proximity of a coronary bifurcation presented lower TAWSS peak values (6.65 [IQR 6.20–13.20] vs. 3.81 [2.53–5.17] Pa, p = 0.008) and hosted less frequently TSVI hot spots (100% vs. 57.1%, p = 0.034). Vascular segments of healed SCAD were characterized by high curvature/torsion and WSS profiles reflecting increased local flow disturbances. Hence, a pathophysiological role of the interaction between vessel anatomy and shear forces in SCAD is hypothesized. Panel A: Baseline coronary angiography (left) showing the target SCAD with yellow arrows pointing to the proximal end of the SCAD. Follow-up coronary angiography (right) showing the complete healing of the vessel without any coronary intervention. Panel B: The healed coronary vessel is reconstructed from the follow-up coronary angiography and vessel curvature and vessel tortuosity peaks are obtained. ' Match ' is defined by the co-localization of high peak curvature or tortuosity hot spots (red markers) with the angiographically-defined SCAD region of interest (ROI, red arrows). Panel C: Results of the computational fluid dynamics (CFD) analysis on the three-dimensional coronary vessel reconstruction. ' Match ' is defined by the co-localization of high time-averaged wall shear stress (TAWSS) or topological shear variation index (TSVI) hot spots (red markers) with the angiographically-defined SCAD ROI (red arrows). [Display omitted] • Native SCAD vessel anatomy can be assessed in spontaneously healed vessels. • Extreme curvature and tortuosity characterize coronaries where SCAD occurred. • Hot spots with aberrant shear stress patterns localized proximally in SCAD regions. • Coronary segments prone to SCAD might be identified with computational models. [ABSTRACT FROM AUTHOR]

The resorbable magnesium scaffold (RMS) is a second-generation bioresorbable scaffold (BRS) that has shown conflicting results in previous studies. These findings suggest that patient selection and implantation technique may have an impact on clinical outcomes. This study aimed to investigate the safety and long-term effectiveness of RMS in a narrowly selected population. SHERPA-MAGIC is an investigator-driven, multicenter, prospective, single-arm study that enrolled patients undergoing BRS coronary implantation in 18 Italian centers. The present analysis considered the first 543 enrolled patients treated with RMS, with a minimum follow-up of 1 year. The study protocol included strict criteria for patient selection and standardization of RMS implantation. The primary outcome was the occurrence of the vessel-oriented composite endpoints (VOCE), including cardiac death, target vessel myocardial infarction, and ischemia-driven target vessel revascularization. Overall, 635 vessels were treated. The 1-year cumulative occurrence of VOCE was 22 (3.5%, 95% CI 2.2%–5.2%), which was significantly lower than the prespecified estimation (from 5.5% to 8.5%). At the median follow-up of 3.5 [2.6–4.3] years, there were 3 (0.5%) cardiac deaths, 12 (1.9%) target vessel myocardial infarctions, and 33 (5.2%) ischemia-driven target vessel revascularizations. A total of 37 (5.8%, 95%CI 4.1%–7.9%) VOCEs were detected. Scaffold thrombosis occurred in 4 (0.6%, 95%CI 0.1%–1.6%) cases. Patient-level analysis confirmed the findings of the vessel-level analysis. These results confirm the safety and performance of RMS technology. If confirmed in randomized controlled trials, they may rekindle interest in the use of scaffolds in daily practice. Central illustration summarizing the qualifying criteria for patient and lesion selection and the standardized RMS implantation technique according to SHERPA-MAGIC protocol. In the bottom panel, the main results of the study are listed: the cumulative occurrence of VOCE at 1 year follow-up and at median follow-up; the cumulative occurrence of POCE at median follow-up; the rate of instent restenosis and Scaffold Thrombosis. [Display omitted] • Resorbable magnesium scaffold (RMS) is a second-generation bioresorbable scaffold (BRS) showing conflicting results in first studies. • The long-term clinical outcome of the first 543 patients enrolled in the SHERPA-MAGIC study expands the recent BIOSOLVE-IV findings. • Indeed, the present results confirm the safety and the good performance of the RMS technology in the treatment of mid-to-large size coronary vessels in a real-world population. • The combination of adequate patient selection and meticulous implantation technique guaranteed to maximize the safety and efficacy of RMS. [ABSTRACT FROM AUTHOR]

Revascularization of left main coronary artery (LMCA) stenosis is mostly based on angiography. Indices based on angiography might increase accuracy of the decision, although they have been scarcely used in LMCA. The objective of this study is to study the diagnostic agreement of QFR (quantitative flow ratio) with wire-based fractional flow reserve (FFR) in LMCA lesions and to compare with visual severity assessment. In a series of patients with invasive FFR assessment of intermediate LMCA stenoses we retrospectively compared the measured value of QFR with that of FFR and the estimate of significance from angiography. 107 QFR studies were included. The QFR intra-observer and inter-observer agreement was 87% and 82% respectively. The mean QFR-FFR difference was 0.047 ± 0.05 with a concordance of 90.7%, sensitivity 88.1%, specificity 92.3%, positive predictive value 88.1% and negative predictive value 92.3%. All these values were superior to those observed with the visual estimation which showed an intra- and inter-observer agreement of 73% and 72% respectively, besides 78% with the FFR value. The low diagnostic performance of the visual estimation and the acceptable performance of the QFR index measurement were observed in all subgroups analysed. QFR allows an acceptable estimate of the FFR obtained with intracoronary pressure guidewire in intermediate LMCA lesions, and clearly superior to the assessment based on angiography alone. The decision to revascularize patients with moderate LMCA lesions should not be based solely on the degree of angiographic stenosis. [Display omitted] • In LMCA the estimation of its functional impact based exclusively on angiography has a low reproducibility and agreement with the FFR. • The decision based exclusively on the visual estimation of angiography can result in inadequate treatment of a lesion in the left main coronary artery. • The use of functional indices based on angiography may be a precise and objective tool for decision making without the need of invasive procedures using pressure wire. [ABSTRACT FROM AUTHOR]

This study aimed to investigate the impact of branch vessel involvement on organ malperfusion and mid-term survival in patients with acute type A aortic dissection (ATAAD). Between January 2019 and December 2020, 493 consecutive patients with angiographically confirmed ATAAD were retrospectively analysed. Preoperative computed tomography angiography parameters (branch artery involvement, longitudinal extent of dissection) were reviewed. The incidence of organ malperfusion, in-hospital mortality, and mid-term outcomes of patients with and without branch vessel involvement were compared. Branch vessel involvement was detected in 407 patients (82.6%), and organ malperfusion was observed in 234 patients (47.5%). The incidence of organ malperfusion was significantly higher in patients with branch vessel involvement compared with patients without it (52.6% vs. 23.3%, p < 0.001). Patients with coronary artery involvement (32.5%) were more likely to manifest as clinical malperfusion, whereas it occurred only 19.4% in patients with renal artery involvement. In-hospital mortality was higher in patients with branch vessel involvement (19.9% vs. 8.1%, p = 0.010). Median follow-up time was 16.1 months. Two-year survival rate was lower in patients with branch vessel involvement (76.3% vs. 84.5%, p = 0.085) or organ malperfusion (68.3% vs. 86.0%, p < 0.001). Multivariable analysis identified cardiac, cerebral, visceral and renal malperfusion as independent predictors for in-hospital mortality. Only a small proportion of branch vessel involvement was associated with corresponding organ malperfusion in patients with ATAAD. Branch vessel involvement had a greater effect on short-term outcomes than mid-term survival, and organ malperfusion was related to a worse prognosis beyond it. • Most patients with ATAAD have branch vessel involvement. • Branch vessel involvement is not always associated with organ malperfusion. • Patients with coronary artery involvement are more likely to manifest as clinical malperfusion. • Patients with branch vessel involvement had a greater impact on in-hospital mortality than 2-year mortality. • Preoperative malperfusion was associated with a worse prognosis beyond branch vessel involvement. [ABSTRACT FROM AUTHOR]

This study aimed to explore the impact of myocardial bridging (MB) on early development of cardiac allograft vasculopathy and long-term graft survival after heart transplantation. MB has been reported to be associated with acceleration of proximal plaque development and endothelial dysfunction in native coronary atherosclerosis. However, its clinical significance in heart transplantation remains unclear. In 103 heart-transplant recipients, serial (baseline and 1-year post-transplant) volumetric intravascular ultrasound (IVUS) analyses were performed in the first 50 mm of the left anterior descending (LAD) artery. Standard IVUS indices were evaluated in 3 equally divided LAD segments (proximal, middle, and distal segments). MB was defined by IVUS as an echolucent muscular band lying on top of the artery. The primary endpoint was death or re-transplantation, assessed for up to 12.2 years (median follow-up: 4.7 years). IVUS identified MB in 62% of the study population. At baseline, MB patients had smaller intimal volume in the distal LAD than non-MB patients (p = 0.002). During the first year, vessel volume decreased diffusely irrespective of the presence of MB. Intimal growth diffusely distributed in non-MB patients, whereas MB patients demonstrated significantly augmented intimal formation in the proximal LAD. Kaplan-Meier analysis revealed significantly lower event-free survival in patients with versus without MB (log-rank p = 0.02). In multivariate analysis, the presence of MB was independently associated with late adverse events [hazard ratio 5.1 (1.6–22.2)]. MB appears to relate to accelerated proximal intimal growth and reduced long-term survival in heart-transplant recipients. • Myocardial bridging in patients after heart transplantation. • might have higher prevalence than considered. • appeared to be associated with accelerated proximal plaque proliferation. • and reduced long-term survival. [ABSTRACT FROM AUTHOR]

The role of Sodium-glucose co-transporter 2 inhibitors (SGLT2i) in heart failure is established. Early data also suggests their favorable role in patients with acute coronary syndromes, but more evidence is still needed. In this dual center, double-blinded randomized controlled trial, non-diabetic patients (N = 100) who presented with anterior ST- elevation myocardial infarction (STEMI) & had undergone successful primary percutaneous coronary intervention, but their left ventricular ejection fraction was below 50%, were randomized to dapagliflozin 10 mg or a placebo once daily. The primary endpoint was a change in cardiac function assessed by N-terminal pro-Brain Natriuretic Peptide – NT-proBNP measured at baseline & 12 weeks post the cardiac event &/or echocardiographic parameters (left ventricular ejection fraction, left ventricular diastolic dimension & left ventricular mass index) assessed at baseline, 4-weeks & 12-weeks post the cardiac event. From October 2021 to April 2022, 100 patients were randomized. The mean drop of NT- proBNP in the study group was more significant compared to the control group by 10.17% (95% CI: −3.28–19.67, p -value 0.034). In addition, the decrease in the left ventricular mass index (LV mass index) was also significant in the study group compared to the control group by 11.46% (95% CI: −19.37 to −3.56, p-value 0.029). Dapagliflozin seems to have a role in preventing left ventricular dysfunction & maintaining cardiac function following anterior ST-elevation myocardial infarction. More Large-scale trials need to be done to confirm these findings further. This trial is locally registered at the National Heart Institute, Cairo – Egypt, and Faculty of Medicine, Ain Shams University, with reference numbers CTN1012021 & MS-07/2022, respectively. It is also registered retrospectively at the US National Institutes of Health (ClinicalTrial.gov) with identifier number: NCT05424315 – June 16th,2022. • In-hospital initiation of dapagliflozin after acute anterior myocardial infarction may have a role in maintaining cardiac function and preventing heart failure post-MI. • Patients taking dapagliflozin over a placebo had significantly lower levels of NT-proBNP and lower left ventricular mass index. [ABSTRACT FROM AUTHOR]

To investigate the correlation between carotid plaque parameters detected on contrast-enhanced ultrasound(CEUS) and the plaque progression in non-culprit coronary lesions (NCCLs) after percutaneous coronary intervention (PCI). In this retrospective cross-sectional study, we analyzed 173 patients who underwent PCI. Patients were stratified into two groups (progression and non-progression groups) by comparing the coronary angiography (CAG) results at baseline and follow-up. The correlation between carotid plaque parameters and plaque progression in NCCLs was analyzed by multivariate logistic regression analysis. A logistic regression model was established to predict NCCLs progression. Overall, 55 of 173 patients exhibited NCCLs progression (31.79%). Univariate comparisons showed that plaque thickness, plaque length, and IPN score were significantly higher in the progressive group than in the non-progressive group (P < 0.01). Multivariate logistic regression analysis revealed that carotid plaque length (OR = 3.418, 95% CI =1.101–10.610) and IPN score (OR = 7.395, 95% CI =3.154–17.342) were strongly associated with plaque progression in NCCLs. After adjusting for confounders, the history of previous PCI, plaque length, and IPN score were independent predictors of the NCCLs progression (P < 0.05). The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the logistic regression model in predicting the NCCLs progression were 62.50%, 90.53%, 81.12%, 76.92%, and 82.69%, respectively, and the area under the receiver operating characteristic (ROC) curve was 0.882 (95% CI: 0.826–0.939). Carotid plaque length and IPN score were strongly correlated with plaque progression in NCCLs. Combining the history of previous PCI can reasonably predict the NCCLs progression. • The plaque thickness, length, and IPN score were significantly higher in the progressive group than in the non-progressive group (P < 0.01). • The plaque length (OR = 3.418, 95% CI =1.101–10.610) and IPN score (OR = 7.395, 95% CI =3.154–17.342) were strongly associated with plaque progression in NCCLs. • The sensitivity, specificity, accuracy, positive and negative predictive value of the logistic regression model in predicting the NCCLs progression were 62.50%, 90.53%, 81.12%, 76.92%, and 82.69%, respectively, and the area under the ROC curve was 0.882 (95% CI: 0.826–0.939). [ABSTRACT FROM AUTHOR]

Heart failure (HF) is a severe complication of acute ST-segment elevation myocardial infarction (STEMI). Its incidence is associated with myocardial infarction location, and it occurs frequently after acute anterior wall STEMI due to the larger infarct size. However, predictors of in-hospital HF in patients with acute anterior wall STEMI are inadequately defined. We aimed to determine potential predictors of HF in patients with acute anterior wall STEMI during hospitalization. A total of 714 consecutive patients who were diagnosed with acute anterior wall STEMI and underwent primary percutaneous coronary intervention (pPCI) between January 2013 to August 2019 were enrolled retrospectively. We assigned the patients to HF and non-HF groups. The clinical parameters were subjected to univariate analysis and logistic regression analysis to obtain the independent predictors. Among the 714 patients enrolled in the present study (mean age 61.0 ± 13.8 years, men 80.7%), 387 (54.2%) had in-hospital HF. According to a multivariate logistic regression analysis, ventricular fibrillation (VF, OR: 5.66, 95% CI: 2.25–14.23, P < 0.001) was the most striking independent predictor of in-hospital HF. Community-acquired pneumonia (CAP, OR: 4.72, 95% CI: 2.44–9.10, P < 0.001), age (OR: 1.03, 95% CI: 1.01–1.04, P < 0.001), left ventricular ejection fraction (LVEF, OR: 0.96, 95% CI: 0.93–0.97, P < 0.001), and peak N-terminal pro-brain natriuretic peptide (NT-pro-BNP, OR: 1.06, 95% CI: 1.02–1.11, P = 0.006) were also independently associated with in-hospital HF. VF, CAP, age, LVEF, and peak NT-pro-BNP were independently associated with in-hospital HF in patients with acute anterior wall STEMI. • In anterior ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention, heart failure remains a common complication. • Ventricular fibrillation, community-acquired pneumonia, age, left ventricular ejection fraction, and peak N-terminal pro-brain natriuretic peptide were independently associated with in-hospital HF in patients with acute anterior STEMI. • Ventricular fibrillation is the strongest independent predictor of heart failure in patients with anterior ST-segment elevation myocardial infarction. [ABSTRACT FROM AUTHOR]

• Myocardial infarction with non-obstructed coronary arteries (MINOCA) is a 'working diagnosis'. • A comprehensive diagnostic evaluation unravels the pathophysiology of MINOCA in the majority of cases. • Intravascular imaging and coronary physiology are needed in Myocardial ischemia with non-obstructed coronary arteries • Magnetic resonance, computed tomography and coagulation testing are fundamental diagnostic complements in MINOCA/INOCA. [ABSTRACT FROM AUTHOR]

A substantial number of patients present with a suspected ACS and non-obstructive coronary arteries; sex differences in these patients are not well understood. This study aims to evaluate the impact of sex on clinical presentation and outcome in patients with suspected acute coronary syndrome (ACS) and non-obstructive coronary arteries with a final diagnosis confirmed by cardiovascular magnetic resonance imaging (CMR). Consecutive patients with ACS and non-obstructive coronary arteries (n = 719) with an unclear cause from a single tertiary centre who were referred for CMR were included. The primary endpoint was all-cause mortality. CMR was performed at a median time of 30 days after presentation and identified a diagnosis in 74% of patients. All-cause mortality was 9.5% over a median follow up of 4.9 years, with no significant difference between sexes (8.8% versus 10.1%; p = 0.456). Men were more likely to have non-ischaemic aetiology on CMR than women (55% v 41%, p < 0.001), but were equally likely to have an ischaemic cause (25% v 27%, p = 0.462). Age group (HR 1.58, p < 0.001) and LV ejection fraction (HR 0.98, p = 0.023) were independent predictors of mortality. There is no difference in all-cause mortality between sexes in patients presenting with suspected ACS and non-obstructive coronary arteries. • All-cause mortality was 9.5% over a median follow up of 4.9 years. • There was no overall difference in mortality by sex. • Mortality is highest in the non-ischaemic group in both sexes. • Men were more likely to have a non-ischaemic aetiology on CMR driven by a higher incidence of myocarditis. [ABSTRACT FROM AUTHOR]

Type A acute aortic dissection (AAD) complicated by coronary malperfusion is a life-threatening disease. In the present study, we compared the clinical characteristics and prognostic impact of treatment strategies including surgical treatment and percutaneous coronary intervention (PCI) in type A AAD patients with RCA and LCA involvement. This multicenter registry included 220 patients with type A AAD and either RCA or LCA involvement. Treatment strategies were left to treating physicians. The primary endpoint was in-hospital death. Of 220 patients, 115 (52.3%) and 105 (47.7%) had RCA and LCA involvement. Patients with LCA involvement were more1 likely to present with Killip class IV on admission than those with RCA involvement. Coronary angiography was performed in 52 of 220 (23.6%) patients, among whom 39 (75.0%) underwent subsequent PCI. During the hospitalization, 93 (42.3%) patients died. Patients with LCA involvement had an increased risk of in-hospital mortality compared to those with RCA involvement (54.3% vs. 31.3%, p < 0.001). In patients with RCA involvement, multivariable analysis identified Killip class IV and no surgical treatment as predictors of in-hospital death, while PCI and surgical treatment were indicated as factors associated with lower in-hospital mortality in patients with LCA involvement. The rates of RCA and LCA involvement were similar in type A AAD. Immediate PCI as a bridge to subsequent surgical treatment might improve survival in patients with type A AAD complicated by coronary malperfusion, especially in those with LCA involvement. • Type A acute aortic dissection (AAD) with coronary malperfusion is a fatal disease. • Prognostic impact of PCI in this setting is unclear. • Primary PCI may improve survival in type A AAD patients with coronary malperfusion. • The PCI effect was primarily seen in patients with left coronary artery involvement. [ABSTRACT FROM AUTHOR]

Background: There is limited information available regarding evidence of ischemia with no obstructive coronary arteries (INOCA) and quality of life. Purpose: To determine associations between INOCA and self-reported physical, social, and mental health. Methods: We conducted a survey of all members (n = 1579) of the INOCA International patient support group. Current self-reported diagnosis and health measures were collected. Functional capacity was retrospectively estimated using the Duke Activity Status Index (DASI), assessing levels of activities performed prior and after symptom onset. Results: A total of 297 (20.8% response rate, 91% women) reported symptoms of chest pain, pressure, or discomfort in 92.9%. Overall, 34.4% were living with symptoms for ≥3 years before an INOCA diagnosis, and 77.8% were told their symptoms were not cardiac. Estimated functional capacity was higher prior to compared to after symptom onset (8.6 ± 1.8 METs vs 5.6 ± 1.8 METs; P < 0.0001). Most respondents reported an adverse impact of symptoms on their home life (80.5%), social life (80.1%), mental health (70.4%), outlook on life (69.7%), sex life (55.9%), and their partner/spouse relationship (53.9%), while approximately three-quarters reduced their work hours or stopped work completely, 47.5% retired early, and 38.4% applied for disability. Conclusions: INOCA symptoms are associated with adverse physical, mental and social health quality of life. Increased patient awareness, physician recognition and diagnosis, and clinical trials are needed to develop evidence-based guidelines for this increasingly recognized cardiovascular disorder. [Display omitted] • INOCA symptoms are associated with adverse physical, mental and social health quality of life. • Increased patient awareness and physician recognition of INOCA are needed. • Future clincial trials are needed to develop evidence-based guidelines for this increasingly recognized cardiovascular disorder. [ABSTRACT FROM AUTHOR]

Coronary endothelial dysfunction and vasospasm are potential causes of ischemia in patients without obstructive coronary stenoses (INOCA). To evaluate the prevalence of endothelial dysfunction and the clinical profile of patients with INOCA in Spain, as well as to identify the predictors and the prognostic impact of endothelial dysfunction in this scenario. A total of 438 consecutive patients with INOCA in whom the acetylcholine test was performed were prospectively enrolled. Patients were followed up at 1 and 2 years. Mean age was 62 ± 11 years with 60% female. Clinical presentation comprised 52.6% angina at rest, 61.2% exertional angina, and 31.7% dyspnea. There were no major complications of the acetylcholine test. Endothelial dysfunction was observed in 198 (45%) of patients, with severe vasoconstriction (defined as over 70% constriction), being observed in 101 (23%). Multivariable regression analysis showed that endothelial dysfunction was predicted by the presence of exertional angina (OR 2.2; CI95%1.01–2.55; p = 0.02), prior coronary disease (OR 2.46; CI95% 1.57–3.89; p < 0.01), and coronary intramyocardial bridging (2.35; CI95% 1.02–5.60; p = 0.04). Patients with endothelial dysfunction presented with worsening angina compared to those without endothelial dysfunction (25.6% vs. 12.8%) and also presented with increased levels of minimal effort angina (40% vs. 26,7%, p = 0.03) more frequently during the follow up than those without endothelial dysfunction. Endothelial dysfunction was also an independent predictor of the occurrence of myocardial infarction or unstable angina at one year (OR 2.85, CI 95% 1.01–9.25; p = 0.03). Endothelial dysfunction is present in almost half of patients with INOCA and is associated with worsening symptoms, as well as with a higher rate of adverse events. [Display omitted] • Almost half of patients with INOCA have coronary endothelial dysfunction. • Exertional angina is a predictor of coronary endothelial dysfunction in INOCA. • Coronary endothelial dysfunction is a predictor of cardiovascular events in patients with INOCA. [ABSTRACT FROM AUTHOR]

Wall shear stress (WSS) is involved in coronary artery plaque pathological mechanisms and modulation of gene expression. This study aims to provide a comprehensive haemodynamic and biological description of unstable (intact-fibrous-cap, IFC, and ruptured-fibrous-cap, RFC) and stable (chronic coronary syndrome, CCS) plaques and investigate any correlation between WSS and molecular pathways. We enrolled 24 CCS and 25 Non-ST Elevation Myocardial Infarction-ACS patients with IFC (n = 11) and RFC (n = 14) culprit lesions according to optical coherence tomography analysis. A real-time PCR primer array was performed on peripheral blood mononuclear cells for 17 different molecules whose expression is linked to WSS. Computational fluid dynamics simulations were performed in high-fidelity 3D-coronary artery anatomical models for three patients per group. A total of nine genes were significantly overexpressed in the unstable patients as compared to CCS patients, with no differences between IFC and RFC groups (GPX1, MMP1, MMP9, NOS3, PLA2G7, PI16, SOD1, TIMP1, and TFRC) while four displayed different levels between IFC and RFC groups (TNFα, ADAMTS13, EDN1, and LGALS8). A significantly higher WSS was observed in the RFC group (p < 0.001) compared to the two other groups. A significant correlation was observed between TNFα (p < 0.001), EDN1 (p = 0.036), and MMP9 (p = 0.005) and WSS values in the RFC group. Our data demonstrate that IFC and RFC plaques are subject to different WSS conditions and gene expressions, suggesting that WSS profiling may play an essential role in the plaque instability characterization with relevant diagnostic and therapeutic implications in the era of precision medicine. • Wall shear stress (WSS) is involved in coronary artery plaque pathological mechanisms and modulation of gene expression. • Different phenotypes of coronary artery plaques (intact fibrous cap and ruptured fibrous cap) are subject to different WSS and gene expression. • The combination of fluid-dynamic with biological profiling might help to characterize coronary artery plaque and to detect unstable ones. [ABSTRACT FROM AUTHOR]

Background Several non-hyperemic pressure-derived Indexes (NHPI) have been introduced for the assessment of coronary stenosis, showing a good correlation with fractional flow reserve (FFR). Notably, either the assessment of NHPI during adenosine administration (NHPI ADO) or the Hybrid Approach (NHPI HA), combining NHPI with FFR, have been showed to increase the accuracy of such indexes. It remains unclear whether diagnostic performance might be affected by the extent of the subtended myocardial mass. Methods. We enrolled consecutive patients with an intermediate coronary stenosis assessed with NHPI and FFR. NHPI were also measured during adenosine (ADO) administration (NHPI ADO). The amount of jeopardized myocardium was assessed using the Duke Jeopardy Score (DJS). With FFR as reference, we assessed the accuracy of NHPI, NHPI ADO and NHPI HA according to the extent of the subtended myocardium. Results. One-hundred-seventy stenoses from 151 patients were grouped according to the DJS as follows: A) Small Extent (SE, n = 82); B) Moderate Extent (ME, n = 53); C) Large Extent (LE, n = 35). As compared with FFR, NHPI showed a significantly different accuracy, as assessed by the Youden's index, according to the extent of the jeopardized myocardium (SE: 0.39 ± 0.05, ME: 0.68 ± 0.06, LE: 0.28 ± 0.06, p < 0.001). Conversely, both the NHPI ADO (SE: 0.76 ± 0.02, ME: 0.88 ± 0.02, LE: 0.82 ± 0.02, p = 0.72) and NHPI HA (SE: 0.82 ± 0.07, ME: 0.84 ± 0.02, LE: 0.88 ± 0.02, p = 0.70) allowed for a better diagnostic accuracy regardless of the amount of myocardium subtended. Conclusions. Diagnostic performance of NHPI might be affected by the extent of myocardial territory subtended by the coronary stenosis. A hybrid approach might be useful to overcome this limitation. • Diagnostic accuracy of NHPI is significantly affected by the extent of myocardium subtended by the coronary stenosis. • A misclassification of intermediated stenoses might occur and the hybrid approach might be useful for a better assessment. • Future studies should consider this limitation promoting the Hybrid Approach for the assessment of coronary artery stenoses. [ABSTRACT FROM AUTHOR]

Among patients who present with acute myocardial infarction (MI), 2–6% are found to have non-obstructive coronary arteries (NOCA). Patients with MINOCA are more commonly women and present at a younger age (51–59 years). The influence of sex on adverse event rates remains unclear. PubMed, MEDLINE, CENTRAL (Cochrane Central Register of Controlled Trials), EMBASE, EBSCO, Web of Science and CINAHL databases were searched for trials comparing gender differences in clinical outcomes among patients with MINOCA from inception through April 10, 2022. The primary endpoint of the study was composite major adverse clinical events (MACE) including all-cause mortality, non-fatal MI, stroke, and cardiovascular readmissions, and secondary endpoints were the individual components of the MACE. Seven studies with a total of 28,671 MINOCA patients were included (n = 11,249 men and n = 17,422 women) over a mean follow-up of 2 years. Women had more MACE than men (10.1% vs. 9.1%, OR 1.15, 1.04–1.23, I2 = 44.7%). Among secondary endpoints, only the incidence of stroke was higher in women (3.5% vs. 2.2%, OR 1.3, 1.01–1.68, I2 = 0%). All-cause mortality, non-fatal MI, and cardiovascular readmissions were not significantly different between the two groups. We hypothesize that small vessel disease associated with MINOCA drives MACE in women and the diminishing influence of estrogen, hypercoagulability and underprescribing could contribute to the differences sex-related outcomes. • The influence of sex on adverse events in MINOCA remains unclear. • Our meta-analysis of >28,000 MINOCA patients showed women had more MACE than men (10.1% vs. 9.1%). • The adverse events in women were driven only by higher incidence of stroke in women (3.5% vs. 2.2%, p < 0.05). • Diminishing influence of estrogen, hypercoagulability, and underprescribing in women are likely contributors to MACE. [ABSTRACT FROM AUTHOR]

Little is known about prevalence and predictors of myocardial infarction with non-obstructive coronary arteries (MINOCA) in Fabry disease (FD) and hypertrophic cardiomyopathy (HCM). We assessed and compared the prevalence and predictors of MINOCA in a large cohort of HCM and FD patients. In this multicenter, retrospective study we enrolled 2870 adult patients with HCM and 267 with FD. The only exclusion criterion was documented obstructive coronary artery disease. MINOCA was defined according to guidelines. For each patient we collected clinical, ECG and echocardiographic data recorded at initial evaluation. Overall, 36 patients had MINOCA during a follow-up period of 4.5 ± 11.2 years. MINOCA occurred in 16 patients with HCM (0.5%) and 20 patients with FD (7.5%; p < 0.001). The difference between the 2 groups was highly significant, also after adjustment for the main clinical, ECG and echocardiographic variables (OR 6.12; 95%CI 2.80–13.3; p < 0.001). In the FD population MINOCA occurred in 17 out of 96 patients with left ventricle hypertrophy (LVH, 17.7%) and in 3 out of 171 patients without LVH (1.7%; OR 12.0; 95%CI 3.43–42.3; p < 0.001). At multivariable analysis, voltage criteria for LVH at ECG (OR 7.3; 95%CI 1.93–27.7; p = 0.003) and maximal LV wall thickness at echocardiography (OR 1.15; 95%CI 1.05–1.27; p = 0.002) maintained an independent association with MINOCA. No major significant differences were found in clinical, ECG and echocardiographic findings between HCM patients with or without MINOCA. MINOCA was rare in HCM patients, and 6-fold more frequent in FD patients. MINOCA may be considered a red flag for FD and aid in the differential diagnosis from HCM. • MINOCA is 6-fold more frequent in Fabry Disease vs Hypertrophic Cardiomyopathy. • MINOCA may be considered a red flag for Fabry Disease. • In Fabry Disease, MINOCA is associated to a more advanced stage of cardiomyopathy. [ABSTRACT FROM AUTHOR]

To investigate geographic disparity in long-term mortality following revascularization in patients with complex coronary artery disease (CAD). The SYNTAXES trial randomized 1800 patients with three-vessel and/or left main CAD to percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) and assessed their survival at 10 years. Patients were stratified according to the region of recruitment: North America (N-A, n = 245), Eastern Europe (E -E, n = 189), Northern Europe (N-E, n = 425), Southern Europe (S-E, n = 263), and Western Europe (W-E, n = 678), which also served as the reference group. Compared to W-E, patients were younger in E-E (62 vs 65 years, p < 0.001), and less frequently male in N-A (65.3% vs 79.6%, p < 0.001). Diabetes (16.0% vs 25.4%, p < 0.001) and peripheral vascular disease (6.8% vs 10.9%, p = 0.025) were less frequent in N-E than W-E. Ejection fraction was highest in W-E (62% vs 56%, p < 0.001). Compared to W-E, the mean anatomic SYNTAX score was higher in S-E (29 vs 31, p = 0.008) and lower in N-A (26, p < 0.001). Crude ten-year mortality was similar in N-A (31.6%), and W-E (30.7%), and significantly lower in E -E (22.5%, p = 0.041), N-E (21.9%, p = 0.003) and S-E (22.0%, p = 0.014). Compared to W-E, adjusted mortality in N-E (HR 0.85, p = 0.019) and S-E (HR 0.72, p = 0.043) remain significantly lower after adjustment for pre- and peri-procedural factors, but no significant interaction (P interaction = 0.728) between region and modality of revascularization was seen. In the era of globalization, knowledge, and understanding of geographic disparity are of paramount importance for the correct interpretation of global studies. [Display omitted] • This is the first report of the geographic disparity in the SYNTAXES trial. • The region was divided into 5 according to the United Nations geoscheme. • Ten-year mortality was significantly higher in Western Europe and North America. • Northern and Southern Europe had lower 10-year mortality even after adjustment. • No significant interactions between the geographic disparity and revascularization. [ABSTRACT FROM AUTHOR]

Background Pediatric multisystem inflammatory syndrome temporally associated with COVID-19 (PIMS-TS) is a serious complication of a previous SARS-CoV-2 infection in the group of pediatric patients. Despite the fact that this disease affects only about 1 of 1000 children, it may be severe, and changes in the cardiovascular system may cause long-term complications and the need for longitudinal patient care. Methods It is a single-center retrospective study considering 51 patients with PIMS-TS. The aim of this study was to analyze patients with PIMS-TS, taking into account demographic data, clinical course, laboratory tests and cardiovascular system assessment (electrocardiography, echocardiography, etc.). Results From June 2020 to October 2021, 51 patients with PIMS-TS were hospitalized in our center. In the studied group, 26/51 children (51%) were girls. The mean age of patients was 7 years. Changes in electrocardiograms were found in 21/51 patients. Echocardiography revealed pericardial fluid in most patients. In addition, heart valve insufficiency was found. Changes in the coronary vessels in the form of dilatations and even aneurysms were found in 42 patients. Myocardial hypokinesis was visualized in more than 1/4 of the patients. Sixteen patients (31.3%) required transfer to the intensive care unit (ICU) due to severe hypotension. Laboratory tests revealed increased levels of markers of heart failure and enzymes of myocardial damage. Conclusions Changes in the cardiovascular system in the course of PIMS-TS are of various nature, but in most patients they require close cardiac supervision and long-term follow-up. • Pediatric multisystem inflammatory syndrome temporally associated with COVID-19 leads to serious complications. • Abnormalities in the cardiovascular system are of various nature. • A close cardiac supervision over these patients is necessary. • Certain laboratory parameters influence severity of changes in the cardiovascular system. [ABSTRACT FROM AUTHOR]

Coronary spasm has been suggested to be the underlying mechanism of chest pain in patients with myocarditis and unobstructed coronary arteries. Here we sought to investigate a potential association between virus type and coronary spasm endotype in patients with biopsy-proven viral myocarditis. A total of 618 consecutive patients with unobstructed coronary arteries who underwent endomyocardial biopsy between 2008 and 2018 were screened. Viral myocarditis defined as (immuno-)histological evidence of myocardial inflammation and proof of viral genome by PCR was confirmed in 114 patients. Of these, 34 patients had undergone additional intracoronary acetylcholine (ACh) testing and served as the final study cohort. Patients in this study were 51 ± 27 years old, 41% were female and mean left ventricular ejection fraction was 58 ± 23%. Most frequently, virus DNA was detected by PCR from parvovirus B19 (PVB19, 59%) and human herpesvirus 6 (HHV6, 26%). ACh testing revealed epicardial spasm in 10 patients (29%) and microvascular spasm in 11 patients (32%). The rate of coronary spasm was higher in patients with PVB19-associated myocarditis compared to those with HHV6-associated myocarditis (80% vs. 33%, p = 0.031). In particular, there was a higher prevalence of microvascular spasm in patients with PVB19 compared to HHV6 infection (45% vs. 0%, p = 0.018). Coronary spasm is a frequent finding in patients with biopsy-proven viral myocarditis supporting the hypothesis that coronary spasm may contribute to chest pain in these patients. We observed a particular association of microvascular spasm with PVB19 infection. • Patients with viral myocarditis often present with chest pain. • Most frequently in lymphocytic myocarditis, PVB19 and HHV6 DNA is detected. • Coronary artery spasm could contribute to chest pain in myocarditis. • We observed an association of PVB19 DNA-positive myocarditis with coronary microvascular spasm. [ABSTRACT FROM AUTHOR]

In today's era of precision medicine a renaissance of functional coronary disease including coronary artery spasm (CAS) can be observed. This development is fueled by novel diagnostic methods as well as first evidence from randomized trials regarding targeted treatment approaches. The present review provides a contemporary update on advances in the pathophysiological understanding, diagnosis, treatment and prognosis of CAS. A MEDLINE/PubMed search within the period from 2010 to 2021 was performed focusing on original articles, randomized clinical trials, meta-analyses and systematic reviews on CAS. Among 1.639 citations, articles that were considered to contain the most important and novel data on CAS were included in this narrative review. These articles comprise reports on new insights into the complex pathophysiology of CAS, state-of-the-art invasive diagnostic procedures, reports on diagnosis of microvascular spasm and diagnosis of CAS in special conditions such as MINOCA, post-PCI angina or myocarditis. Moreover, novel treatment approaches are included such as nebivolol, endothelin-1-receptor antagonists and soluble guanylate cyclase stimulators. Furthermore, recent follow-up studies have provided new data on long-term prognosis of affected patients. Scientific progress during the last decade has led to a better understanding of CAS. Today, standardized international diagnostic criteria are available and promising randomized treatment trials are on their way. Moreover, there has been increasing evidence regarding the prognostic value of CAS testing. However, despite many advances, CAS remains a complex and not fully understood condition and more research is needed to better characterize and treat affected patients. • Epicardial and microvascular coronary spasm are frequent mechanisms of angina. • Endothelial dysfunction and VSMC hyperreactivity are responsible for coronary spasm. • Coronary spasm is associated with increased morbidity but not mortality. • Trials investigating targeted medical treatment of coronary spasm are underway. [ABSTRACT FROM AUTHOR]

The literature on prevalence and outcomes of coronary artery aneurysm (CAA) in the United States (US) is limited. To study the prevalence, outcomes, and trends of CAA. Data from the national readmissions database (NRD) sample that constitutes 49.1% of the stratified sample of all hospitals in the US were analyzed for CAA among coronary angiography (CA) related hospitalizations for the years 2012–2018. A total of 6,843,910 index CA related hospitalizations were recorded for the years 2012–2018 in the NRD (Mean age 64.37 ± 13.30 years' 38.6% females). Of these 9671 (0.141%) were CAA, 5092 (52.7%) without-ACS and 4579 (47.3%) with ACS [NSTEMI occurred in 2907(63.5%) and STEMI in 1672(36.5%)]. In-hospital mortality among CAA was comparable to those without-CAA on angiography (n-209,2.17% vs n = 175,120,2.56%; p = 0.08). CAA patients who presented with ACS vs those without ACS had higher mortality (n = 150,3.28%vsn = 60,1.16%; p < 0.001) cardiogenic shock 6.9%vs2%, ventricular arrythmias 9.2%vs5.2%, coronary dissection 58%vs42.7%, and need for mechanical circulatory support 7%vs2.7% respectively. Percutaneous coronary intervention (PCI) was performed among 45.2% patients; however, on coarsened exact matching of baseline characteristics, PCI had no association with mortality, patients (OR 1.22, 95%CI0.69–2.16, p = 0.49). The prevalence of CAA on CA trend towards increased mortality with ACS increased over the years 2012–2018 (linear p-trend <0.05). The 30-day readmissions rate were 13.8% (non-CAA) vs 4.6% (CAA) p = 0.001 predominantly cardiovascular causes (50.9%vs70.7%) and PCI on readmission (7.06%vs17.5%). CAA is an uncommon anomaly noted on coronary angiography. The higher mortality in patients with ACS and increasing trend of CAA-ACS warrants more research. Central Illustration. Graphical representation for the possible complications associated with coronary artery aneurysm patients with acute coronary syndrome. (Created with Biorender.com). [Display omitted] • The prevalence of CAA was 14 per 10,000 coronary angiographies in NRD 2012-2018. • Patients with acute MI and CAA had higher mortality rates and higher need for mechanical circulatory support. • CAA trend increased over 2012-2018 as did the mortality in patients within ACS subgroup of CAA. • CAA patients had lower rates of 30-day readmissions, however, higher rates of PCI on readmission. • Half of the patients with CAA had associated spontaneous coronary artery dissection recorded in the hospitalization encounters. [ABSTRACT FROM AUTHOR]

In significant obstructive coronary artery disease (SOCAD), a mismatch in assessment of severity of coronary artery stenosis may occur between invasive coronary angiography (ICA) and computed tomography (CT) derived fractional flow reserve (FFR CT). The present study aimed to identify the factors giving an FFR CT > 0.80 and leading to an underestimation of coronary artery severity in SOCAD vessels. A total of 141 consecutive patients who underwent both CT angiography including FFR CT and ICA, the latter showing >75% coronary artery stenosis were evaluated. Vessels were divided into two groups according to FFR CT at the distal aspect of the vessel: FFR CT > 0.80 (n = 12) and FFR CT ≤ 0.80 (n = 153). Vessel morphology, plaque characteristics, left-ventricular (LV) wall thickness at each site of the myocardium, and LV mass were also assessed. LV myocardium-related parameters including LV wall thickness (base, middle, apex, average, and maximal), LV mass, and LV mass index were higher in FFR CT > 0.80, whereas vessel-related parameters including, vessel morphology and plaque characteristics were not significantly different between >0.80 and < 0.80. Vessel morphology and plaque characteristics had no effect on FFR CT , whereas maximum LV wall thickness, LV mass, and LV mass index influenced FFR CT. LV mass index was the strongest predictor of distal FFR CT > 0.80 with an area under the curve of 0.81, and an optimal cut-off value of 66.5 g/m2 (sensitivity 77.8%, specificity 89.6%). The presence of a high LV mass is a major cause for underestimation of coronary artery severity on FFR CT in SOCAD vessels. LV myocardium-related parameters should be considered when interpreting numerical values of FFR CT. [Display omitted] • All levels of LV wall-thickness were higher in FFR CT > 0.80 than FFR CT ≤ 0.80. • Vessel-related and plaque characteristics parameters were not related to FFR CT. • Left ventricular myocardium-related parameters correlated with FFR CT. • Left ventricular mass index of 66.5 g/m2 was the strongest predictor of a distal FFR CT of >0.80. [ABSTRACT FROM AUTHOR]

Clinical outcomes of stable angina patients treated according to guidelines recommendations (medical therapy first, selective revascularization in high risk or unresponsive patients) are not fully known. Eight hundred thirty-three patients with newly diagnosed, stable angina were enrolled in a prospective, observational, nationwide registry and followed for 1 year. Symptoms and quality of life were evaluated with the CCS angina grading, with a self-assessment scale and with the SAQ-7. A composite end-point of MACEs (all-cause death, non-fatal myocardial infarction, non-fatal stroke or hospitalization for unstable angina) at 1 year was considered. Upon enrollment, all patients were prescribed guidelines directed medical therapy. After one month of therapy, angina relieved or improved in 47% of the overall population. Patients in CCS class I significantly increased from 28.4% at enrollment to 67.1% at 12 months, and the SAQ-7 score from 58.4 ± 20 to 85.9 ± 14. The rate of MACEs was low (2.9%) in the overall population. After one month of medical therapy, 40.6% of patients were referred for coronary angiography and revascularization for resistant symptoms (invasive strategy). Among these, 38.2% had normal coronary arteries and 47% actually underwent revascularization. No difference between invasive and medical groups was found at 12 months in symptoms, quality of life and MACEs, except for a greater improvement in self-assessed symptoms in the invasive group. Combined medical and invasive strategies left 28.5% of patients still symptomatic at the end of the study. The study confirms the efficacy and safety of a tailored approach to stable angina, as recommended by guidelines, with medical therapy first followed by selective revascularization when needed. [Display omitted] [ABSTRACT FROM AUTHOR]

To date there are no recommendations on how to treat patients with an FFR positive but diffusely diseased left anterior descending coronary artery (LAD). Benefit of coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) is not so evident due to doubts regarding longevity and patency. This retrospective single-center study assessed clinical outcomes in patients presenting with symptomatic single vessel coronary artery disease of a diffusely diseased, hemodynamically significant LAD treated by coronary artery bypass grafting (CABG) or optimal medical therapy (OMT) between 2015 and 2020. Primary outcome of this study was the composite endpoint of all-cause mortality, myocardial infarction and repeat revascularization during 2-year follow-up. Secondary endpoints consisted of the individual components of the primary endpoint. Change in angina severity grade based on the Canadian Cardiovascular Society (CCS) class between baseline and 2-year follow-up was assessed. Fifty-nine patients were included of which 25 patients underwent CABG and 34 patients were treated by OMT. There was a statistically significant difference in FFR value at baseline between the treatment groups (CABG 0.70 ± 0.04; OMT 0.75 ± 0.04; p < 0.001). After 2-year follow-up, there were no statistically significant differences with regard to the primary endpoint (CABG 16% (n = 4); OMT 17.6% (n = 6); p = 1.00) and secondary endpoints between the groups over 2-year follow-up. In patients with hemodynamically significant diffuse single vessel coronary artery disease of the left anterior descending, there was no difference between OMT and CABG in terms of mortality, myocardial infarction, revascularization and symptom reduction after two years of follow-up. • This study investigated treatment options for significant but diffuse coronary artery disease of the LAD. • There were similar rates of all-cause mortality, myocardial infarction and repeat revascularization between CABG and OMT. • Use of healthcare services and angina symptoms were similarly distributed between the study groups. • Both findings are also applicable to a subgroup of patients with FFR ≤ 0.75 • These results show that revascularization might not be superior to OMT, as is the case in focal LAD disease. [ABSTRACT FROM AUTHOR]

Myocardial infarction with non-obstructed coronary arteries (MINOCA) is a distinct entity among patients presenting with troponin-positive acute chest pain. We have previously reported on the incremental diagnostic capability of cardiovascular magnetic resonance (CMR) in this cohort. There is paucity of evidence on the long-term (> 5 years) clinical outcomes of these patients as graded by their acute CMR diagnosis. A total of 229 patients with a working diagnosis of MINOCA who underwent CMR assessment during the acute admission (2010–2017) were prospectively studied. The primary endpoint was major adverse cardiac events (MACE) defined as a composite of all-cause mortality and cardiovascular readmissions, identified from hospital and primary care records. CMR performed at a median of 6 days (IQR 2, 8) from presentation provided a diagnosis in 85% of the patients (38% myocarditis, 28% acute myocardial infarction and 19% Takotsubo cardiomyopathy). Over a median follow-up of 7.1 years (IQR 3.7, 8.2), 56 (24%) patients experienced a MACE. We found a strong association between CMR diagnosis and MACE (log rank 30.47, p < 0.001). In multivariate analysis, age (hazard ratio = 1.07; 95% confidence interval = 1.05, 1.10; p < 0.001) and CMR diagnosis of acute myocardial infarction (hazard ratio = 8.87; 95% confidence interval = 2.58, 30.4; p = 0.001) were independent predictors of MACE. In a large cohort of patients with a working diagnosis of MINOCA, one in four suffer a MACE during long-term clinical follow-up. CMR diagnosis of acute myocardial infarction and age were significant predictors of MACE even in the absence of significant coronary artery obstruction. [Display omitted] • MINOCA is a distinct clinical entity with different pathophysiological causes. • CMR is a key investigation in patients presenting with a working diagnosis of MINOCA. • One in four patients suffer a MACE during long-term clinical follow-up. • In patients with a working diagnosis of MINOCA, CMR diagnosis of AMI is a significant predictor of MACE. [ABSTRACT FROM AUTHOR]

A large proportion of patients with suspected obstructive coronary artery disease (CAD) is found to have ischemia with no obstructive coronary artery disease (INOCA). Based on current evidence, these patients are at increased risk of adverse cardiovascular events, even though they have no obstructive CAD. Importantly, INOCA is associated with recurrent clinical presentations with chest pain, impaired functional capacity, reduced health-related quality of life, and high healthcare costs. Underlying coronary microvascular dysfunction (CMD), through endothelium-dependent and independent mechanisms contribute to these adverse outcomes in INOCA. While non-invasive and invasive diagnostic testing has typically focused on identification of obstructive CAD in symptomatic patients, functional testing to detect coronary epicardial and microvascular dysfunction should be considered in those with INOCA who have persistent angina. Current diagnostic methods to clarify functional abnormalities and treatment strategies for epicardial and/or microvascular dysfunction in INOCA are reviewed. • Patients with myocardial ischemia and no obstructive coronary arteries (INOCA) are at risk of major cardiovascular events. • Coronary vascular dysfunction may contribute to abnormal coronary blood flow and ischemia. • Stress testing can detect low vasodilatory reserve, but invasive testing is needed to assess coronary endothelial dysfunction. • Invasive functional coronary angiography can provide a diagnosis and guide therapeutic management. • Anti-anginal and anti-atherosclerotic medications are used to manage INOCA, while large trials of outcomes are underway. [ABSTRACT FROM AUTHOR]

Coronary artery ectasia (CAE) is associated with ascending aortic (AA) ectasia. The purpose of this study is to evaluate the diagnostic performance of different echocardiographic parameters (EP) in predicting the presence of CAE. Four hundred-eighteen patients with AA ectasia candidate to coronary angiography were identified and divided in two groups in respect of the presence of CAE. Receiver-operating characteristic curves areas (AUC) were used to assess the discrimination power of the following EP: aortic annulus diameter, sinuses of Valsalva (SV) diameter, sino-tubular junction (STJ) diameter, AA diameter, STJ to SV ratio (STJ-to-SV) and STJ to AA ratio (STJ-to-AA). All these parameters were indexed by body surface area. The relationship between the best EP and the presence of CAE was investigated by means of multivariable logistic regression. The rate of CAE in the study population was 32%. On univariable logistic regression, aortic annulus, STJ, STJ-to-SV and STJ-to-AA were associated with the presence of CAE after Bonferroni correction. STJ-to-SV emerged as the parameter with the best discrimination power (AUC = 0.81) compared to STJ (AUC = 0.69), STJ-to-AA (AUC = 0.68), aortic annulus (AUC = 0.59), AA (AUC = 0.56) and SV (AUC = 0.55); (p for comparison <0.01). An 89.6% value for STJ-to-SV ratio emerged as the best cut-off to diagnose CAE with a sensitivity = 75%, specificity = 82%, positive predictive value = 66% and negative predictive value = 88%. On multivariable analysis, STJ-to-SV was still associated with the presence of CAE (OR = 1.15;95%CI:1.11–1.19; p < 0.01). In patients with dilated aorta, STJ-to-SV sampled by transthoracic echocardiography shows a good diagnostic performance in predicting the presence of CAE. Non invasive predictor of coronary artery ectasia: sino-tubular junction diameter to sinus of Valsava diameter ratio at transthoracic echocardiography is a good tool to prognosticate the presence of coronary artery ectasia at coronary angiography in patients with ascending aorta dilatation. [Display omitted] • Coronary ectasia (CAE) is linked to ascending aortic aneurysms, but not all of them are affected by CAE. • Coronary angiography is the gold standard for CAE diagnosis. • Echo assessment was done in all patients candidate to coronary angiography with ascending aorta ≥4 mm. • Angiography presence of CAE let us to compare the two groups. • The sino-tubular junction to sinus of Valsalva ratio is the best echo predictor of CAE. [ABSTRACT FROM AUTHOR]

Distal transradial artery access (DTRA) has recently gained attention due to potential benefits in terms of local complications. In this meta-analysis, we aimed to evaluate the utility of DTRA compared to conventional transradial artery access (CTRA) for coronary angiography and intervention. Multiple databases were searched from inception through May 2021 for all the studies that evaluated the efficacy and safety of DTRA in the coronary field. The primary outcome was the access success rate. The secondary outcomes were periprocedural local complications (site hematoma, radial artery occlusion, and spasm) and procedural characteristics (cannulation, fluoroscopy, procedure, and radial artery compression times). All meta-analyses were conducted using a random-effect model. A total of 12 studies (including four randomized control trials) with 1634 patients who underwent DTRA vs. 1657 with CTRA were included in the final analysis. The access success rate was similar between the two groups (odds ratio (OR):0.62; 95% confidence interval (CI):0.30–1.26; P = 0.18; I2 = 61%). DTRA was associated with a statistically significant lower rate of radial artery occlusion (OR:0.36; 95% CI: 0.22–0.59; P < 0.001; I2 = 0%) but similar rates of radial artery spasm and site hematoma when compared to CTRA. Regarding the procedural characteristics, despite having a longer canulation time (mean difference (min.) [MD] 0.89, 95% CI 0.36–1.42; P < 0.0001), DTRA was associated with shorter compression time and comparable fluoroscopy and procedure times. Our meta-analysis demonstrates that the DTRA is effective and safe with superiority in preventing radial artery occlusion when compared to CTRA. [Display omitted] • Distal trans-radial artery access (DTRA) seems to have an excellent efficacy in coronary artery angiography and intervention. • The access success rate was 94.3%, which is comparable with the proximal radial approach. • The distal approach significantly reduced the rate of radial artery occlusion. • The distal radial approach was associated with a higher rate of cannulation failure. [ABSTRACT FROM AUTHOR]

Functional coronary disorders such as coronary spasm and microvascular dysfunction (including microvascular spasm and impaired microvascular dilatation) are frequent findings among patients with angina and non-obstructed coronary arteries (ANOCA). In this study, we investigated a potential association of coronary spasm and myocardial perfusion abnormalities as well as predictors of such functional coronary disorders in ANOCA patients using a multimodality diagnostic strategy including adenosine stress CMR and intracoronary acetylcholine testing. We enrolled 129 patients with ANOCA who underwent acetylcholine testing and adenosine stress perfusion CMR. Patients were allocated to 3 groups according to their spasm testing result with regard to standardized COVADIS criteria: 1) epicardial spasm, 2) microvascular spasm, and 3) no spasm. The myocardial perfusion reserve index (MPRI) was semiquantitatively determined from adenosine stress perfusion CMR. Multivariate regression analyses were performed to identify predictors of coronary functional disorders. Patients with epicardial spasm had lower MPRI than patients without, whereas MPRI was preserved in patients with microvascular spasm. Multivariate analyses revealed age, previous myocardial infarction, LVEF and epicardial spasm as independent predictors of diminished MPRI, whereas previous PCI was associated with epicardial spasm, and female sex was a strong predictor of microvascular spasm. Our results demonstrate coexistence of different functional coronary disorder endotypes involving the macro- and microvascular level of the coronary circulation in patients with ANOCA. We demonstrate that epicardial spasm is associated with diminished myocardial perfusion reserve and report further predictors of coronary functional disorders. • Assessment of vasomotor dysfunction by CMR and acetylcholine testing is feasible. • Coronary artery spasm and impaired microvascular vasodilation coexist. • Age and previous myocardial infarction are independent predictors of low MPRI. • Epicardial spasm is associated with low MPRI. • Prior PCI is predictive for epicardial spasm and female sex for microvascular spasm. [ABSTRACT FROM AUTHOR]

Background : Anomalous aortic origin of a coronary artery, particularly in the presence of inter-arterial course between the great arteries, has been found to be associated with sudden death in young people. Methods: This study reports a single-center experience in the management of anomalous aortic origin of a coronary artery, with or without inter-arterial course, by focusing specifically on presentation, diagnosis, and patient outcome. Results : From March 1993 to February 2018, 100 patients (70 males) were diagnosed with anomalous aortic origin of a coronary artery, including 27 left coronary artery from the right sinus, 60 right coronary artery from the left sinus, and 13 other anomalies. Patients with inter-arterial course between the great arteries presented more frequently with syncope and/or sudden death compared to patients without (23.4% vs. 0%, p = 0.026). Diagnosis was reached using first-line transthoracic echocardiography in 65% of cases. Surgical repair was performed in 61 patients (61%). All operated patients (60 direct implantations, 1 unroofing) had been diagnosed with inter-arterial course between the great arteries, and were asymptomatic at a mean (±SD) postoperative follow-up of 4.9 ± 5.3 years. Conclusions: An inter-arterial course of the anomalous right or left coronary arteries arising from the opposite sinus is associated with life-threatening events. Direct reimplantation of coronary artery is reliable, and should be discussed even in asymptomatic patients. • Severe symptoms at presentation were associated with inter-arterial course with or without intramural segment. • More than half of asymptomatic patients were diagnosed with an at-risk coronary artery course between great vessels. • Severe symptoms can occur in right coronary artery from the opposite sinus. • Surgical reimplantation can be performed technically with favorable outcomes in all patients. • Timing of surgery in asymptomatic patients with right or left coronary artery from opposite sinus is debatable. [ABSTRACT FROM AUTHOR]

Background A new imaging metric using coronary computed tomography angiography (CCTA), addressing the peri-coronary adipose tissue (PCAT) computed tomography (CT) attenuation, has been clinically validated. This method provides information regarding coronary inflammation. It is unclear how coronary inflammation affects microvascular function. The non-invasive evaluation of coronary flow velocity reserve is widely used in clinical practice using Doppler measurement on the left anterior descending coronary artery (CFVR-lad) during stress-echocardiography (SE). We hypothesize that coronary inflammation affects CFVR-lad and, in the absence of overt CAD, they are significantly correlated. Methods We evaluated the relationship between coronary inflammation (by PCAT CT attenuation) and coronary microvascular function (by CFVR-lad) in subjects with no or non-obstructive (diameter stenosis <70%) coronary artery disease (CAD). Results Two-hundred and two subjects were enrolled in the study. The relationship between PCAT CT attenuation and CFVR-lad show a significant inverse relationship in the entire group of subjects enrolled in the study (r = −0.32, p < 0.001). Correlation between PCAT CT attenuation and CFVR-lad was significant in subjects with no or mild CAD-lad, while this was not the case in subjects with intermediate CAD-lad. The R and R2 were respectively −0.40, −0.16 in subjects without CAD (p < 0.001) and − 0.35 and − 0.12 in subjects with mild CAD-lad (p = 0.001). Conclusions The main finding of the current study is the independent relationship between coronary microvascular function, by Doppler CFVR-lad during SE, in subjects without severely obstructive CAD in the left anterior descending coronary artery, and the level of local coronary inflammation, by PCAT attenuation measurement on CCTA. • Doppler coronary flow velocity reserve represents microcirculatory function in subjects without obstructive coronary artery disease. • Peri-coronary adipose tissue attenuation on computed tomography represents coronary inflammation. • These two markers did significantly correlate in subjects with no or non-obstructive coronary artery disease. [ABSTRACT FROM AUTHOR]

The impact of a non-dominant right coronary artery (NDRCA), on single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI)has not been clarified. We compared SPECT-MPI results of consecutive patients without significant (diameter stenosis ≥50%)coronary artery disease (CAD) and a NDRCA (Group-1), with those of patients from our database without CAD and a dominant RCA (Group-2). All patients were subjected to SPECT-MPI with I.V. infusion of adenosine, and TC99-tetrofosmin. Group-1 included 69 patients (55 men, 79.7%), mean age 66.8 ± 9.8 years. Group-2 consisted of 79 patients (56 men, 70.9%), mean age 62.7 ± 11.5. There was no difference in demographics and CAD risk factors between the two groups. The SPECT-MPI revealed inferior wall ischemia, in 35 patients (50.7%), in Group-1 and 27 patients (34.1%), in Group-2 (P = 0.041). A relatively high rate of reversible SPECT-MPI perfusion defects may be anticipated in patients with an unobstructed NDRCA compared to patients with a dominant RCA. • A non-dominant right coronary artery (NDRCA) is found in approximately 7–9% of the general population. Its impact –if any- on single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), has not been studied prospectively. • We compared SPECT-MPI results between 69 consecutive patients without significant, coronary artery disease (CAD) and 79 patients with a dominant-RCA, also without significant CAD. There was no difference in demographics between the two groups. The SPECT-MPI revealed ischemia in 50.7%, patients with NDRCA and 34.2%, in patients with a dominant RCA, P = 0.041. • The semiquantitive segmental analysis of radiotracer uptake in the inferior wall revealed that the difference between the perfusion score at stress and rest (SDS), was significantly higher (1.25 ± 1.45 vs. 0.77 ± 1.08, P = 0.028), in patients with NDRCA compared to the rest. • In summary this study shows that a relatively high rate of reversible SPECT-MPI perfusion defects may be anticipated in patients with an unobstructed NDRCA compared to patients with a dominant RCA. [ABSTRACT FROM AUTHOR]

Anomalous coronary artery originating from the opposite sinus of Vasalva with interarterial course (ACAOS-IAC) is associated with sudden cardiac death (SCD) in young athletes. If identified in adulthood prognosis is usually more benign, resulting in a dilemma regarding revascularization. This is a retrospective observational single-center study, including adults with ACAOS-IAC. Medical records between 2012 and 2019 were reviewed for management approach, mortality, cardiac death and coronary related adverse events. Coronary computed tomographic angiography (CCTA) were reviewed. We provide a literature review in regard to clinical outcome. We identified 40 patients with ACAOS-IAC (mean age 51). Presentation was acute in 7/40 (18%). Ischemia detection with single photon emission tomography (SPECT), cardiac magnetic resonance (CMR) or dobutamine stress echocardiography were performed in 25/40 (63%) patients. Ischemia in the vascular territory of the anomaly was present in 2/25 (8%). In 39/40 (98%) patients were treated expectative. During median follow-up of 2.7 years (IQR 1.5–5.3) no cardiovascular death was observed. Mortality occurred in 1/40 (3%) and coronary related adverse events in 2/40 (5%). We identified 20 studies describing 1194 patients. Revascularization was performed in 376/1154 (32.6%) patients. Mortality stratified for clinical management was 23/431 (5.3%) in the non-revascularization versus 16/253 (6.3%) in the revascularization group during 4.0 years follow-up (weighted median). Cause of death was cardiovascular in 10/596 (1.7%) in 4.2 years (weighted median) follow up. Both revascularization and non-invasive management have good prognosis in adults with ACAOS-IAC during early follow up. There is need for guidelines and long-term surveillance. • Adults with interarterial coronary artery show benign prognosis treated expectative • Benefit of revascularization for adults not demonstrated in literature • Prognostic value of high-risk anatomic features show conflicting results [ABSTRACT FROM AUTHOR]

Ischemia with non-obstructive coronary arteries (INOCA) is not uncommon in clinical practice. However, the incidence and imaging characteristics of INOCA on dynamic CT myocardial perfusion imaging (CT-MPI) remains unclear. We aimed to investigate the prevalence and disease features of INOCA as evaluated by dynamic CT-MPI + coronary CT angiography (CCTA). Patients with suspected chronic coronary syndrome and intermediate-to-high pre-test probability of obstructive CAD (according to updated Diamond and Forrester Chest Pain Prediction Rule) were referred for dynamic CT-MPI + CCTA and retrospectively included. Various parameters, including myocardial blood flow (MBF) and high-risk plaque (HRP) features, were measured. INOCA was diagnosed if patients were revealed to have myocardial ischemia and absence of obstructive stenosis. 314 patients were finally included. 20 patients (6.4%) were observed to have myocardial ischemia without obstructive stenosis. In addition, 138 patients (43.9%) had normal or near normal findings, 101 patients (32.2%) had obstructive stenosis without myocardial ischemia and 55 patients (17.5%) had obstructive stenosis with myocardial ischemia. Compared with patients with normal/near normal findings, patients with INOCA showed a higher prevalence of positive remodeling (40.0% vs. 17.4%, p = 0.04). In patients with obstructive stenosis, the mean age, calcium score and incidence of spotty calcification, positive remodeling as well as HRPs were significantly higher than those in patients with INOCA (p < 0.05 for all). The overall prevalence of INOCA was low in patients with suspected chronic coronary syndrome. HRPs were less frequently presented in patients with INOCA, compared with patients having obstructive coronary stenosis. • The overall prevalence of INOCA was low (6.4%) in patients with stable angina. • HRPs were less frequently presented in patients with INOCA. • Dynamic CT-MPI + CCTA was helpful for accurate "one-stop shop" imaging of INOCA. [ABSTRACT FROM AUTHOR]

Risk stratification in anomalous aortic origin of a coronary artery (AAOCA) is challenged by the lack of a reliable method to detect myocardial ischemia. We prospectively studied the safety and feasibility of Dobutamine stress-cardiac magnetic resonance (DSCMR), a test with excellent performance in adults, in pediatric patients with AAOCA. Consecutive DSCMR from 06/2014–12/2019 in patients≤20 years old with AAOCA were included. Hemodynamic response and major/minor events were recorded. Image quality and spatial/temporal resolution were evaluated. Rest and stress first-pass perfusion and wall motion abnormalities (WMA) were assessed. Inter-observer agreement was assessed using kappa coefficient. A total of 224 DSCMR were performed in 182 patients with AAOCA at a median age of 14 years (IQR 12, 16) and median weight of 58.0 kg (IQR 43.3, 73.0). Examinations were completed in 221/224 (98.9%), all studies were diagnostic. Heart rate and blood pressure increased significantly from baseline (p < 0.001). No patient had major events and 28 (12.5%) had minor events. Inducible hypoperfusion was noted in 31/221 (14%), associated with WMA in 13/31 (42%). Inter-observer agreement for inducible hypoperfusion was very good (Κ = 0.87). Asymptomatic patients with inducible hypoperfusion are considered high-risk and those with a negative test are of standard risk. DSCMR is feasible in pediatric patients with AAOCA to assess for inducible hypoperfusion and WMA. It can be performed safely with low incidence of major/minor events. Thus, DSCMR is potentially a valuable test for detection of myocardial ischemia and helpful in the management of this patient population. [Display omitted] • Dobutamine stress CMR has excellent performance in adults with ischemic heart disease. • DSCMR with first pass perfusion is safe and feasible in pediatric patients with AAOCA. • DSCMR results guide management of AAOCA using shared decision making with families. • Most DSCMR after AAOCA surgery were negative and allowed for return to activities. [ABSTRACT FROM AUTHOR]

Measurement of the coronary artery calcification score using multidetector computed tomography (MDCT) is a useful noninvasive test for the diagnosis of coronary artery disease. However, whether pre-intervention assessment of the target vessel coronary artery calcification (TV-CAC) score is associated with stent expansion failure and future target lesion revascularization (TLR), remains unknown. This study aimed to determine the association between the TV-CAC score measured by MDCT and stent expansion rate in patients who underwent IVUS-guided PCI for stable angina. We conducted a retrospective observational study including 135 consecutive patients (186 target lesions) who underwent MDCT and were scheduled for the first PCI. The patients were divided into 2 groups based on the median value of the TV-CAC score. The primary outcome was the stent expansion rate measured by IVUS after stent implantation. The secondary outcome was TLR within 1 year. Stent expansion rate was associated with the TV-CAC score (p < 0.001). According to the ROC curve analysis, the TV-CAC score had the largest area under the curve (AUC) for the stent expansion area of 0.90 (AUC = 0.893, p < 0.001). The TV-CAC score was a positive predictor for stent expansion rate of <90% (odds ratio: 7.54, p < 0.001). Mediation analysis showed that stent under-expansion was a mediator of the association between high TV-CAC and TLR. Our study demonstrates that pre-intervention assessment of TV-CAC using MDCT is a predictor of stent expansion. The TV-CAC score might predict the complexity and help in the PCI operative strategy. • The present study showed that high TV-CAC assessed using the multidetector computed tomography is a predictor of stent under-expansion. • Stent under-expansion is a mediator of the association between high TV-CAC score and in-stent restenosis. • Assessing the TV-CAC score before PCI might be clinically useful to reduce future TLR due to stent under-expansion. [ABSTRACT FROM AUTHOR]

This study aimed to assess the correlation between the standard of care, the index of microvascular resistance (IMR) versus the novel microvascular resistance (R micro) and to determine the pathologic cut-off value in a selected population with suspected coronary microvascular dysfunction (CMD). One-hundred and twenty patients with high clinical suspicion of CMD due to ischemic symptoms in the absence of significant epicardial coronary lesions were prospectively included. Following a standardized systematic protocol, coronary flow reserve, IMR, fractional flow reserve, Q and R micro were measured in the left anterior descending coronary artery using a temperature/pressure sensor-tipped guidewire and a dedicated infusion catheter. There was a high prevalence of CMD with 50 (42%) patients showing an IMR ≥ 25. Median IMR was 23 [IQR: 14–34] and median R micro was 464 Woods Units (WU) [IQR: 354–636WU]. ROC analyses identified 500 WU as the optimal R micro cut-off to identify patients with an IMR ≥ 25, with an area under the ROC curve (C statistic) of 0.83 (95% CI: 0.74 to 0.89, p < 0.0001). R micro derived from continuous intracoronary thermodilution is an accurate index to measure microvascular resistances enabling the invasive diagnostic of CMD. • The presence of coronary microvascular dysfunction can be accurately diagnosed by measuring the minimum microvascular resistance obtained by the continuous thermodilution method. • We found that a continuous thermodilution resistance value >500 WU predicts the presence of coronary microvascular dysfunction. [ABSTRACT FROM AUTHOR]

Accurate segmentation of the coronary arteries with intravascular ultrasound (IVUS) is important to optimize coronary stent implantation. Recently, deep learning (DL) methods have been proposed to develop automatic IVUS segmentation. However, most of those have been limited to segmenting the lumen and vessel (i.e. lumen-intima and media-adventitia borders), not applied to segmenting stent dimension. Hence, this study aimed to develop a DL method for automatic IVUS segmentation of stent area in addition to lumen and vessel area. This study included a total of 45,449 images from 1576 IVUS pullback runs. The datasets were randomly split into training, validation, and test datasets (0.7:0.15:0.15). After developing the DL-based system to segment IVUS images using the training and validation datasets, we evaluated the performance through the independent test dataset. The DL-based segmentation correlated well with the expert-analyzed segmentation with a mean intersection over union (± standard deviation) of 0.80 ± 0.20, correlation coefficient of 0.98 (95% confidence intervals: 0.98 to 0.98), 0.96 (0.95 to 0.96), and 0.96 (0.96 to 0.96) for lumen, vessel, and stent area, and the mean difference (± standard deviation) of 0.02 ± 0.57, −0.44 ± 1.56 and − 0.17 ± 0.74 mm2 for lumen, vessel and stent area, respectively. This automated DL-based IVUS segmentation of lumen, vessel and stent area showed an excellent agreement with manual segmentation by experts, supporting the feasibility of artificial intelligence-assisted IVUS assessment in patients undergoing coronary stent implantation. • We developed a deep learning-based intravascular ultrasound segmentation model. • It provided excellent segmentation performance compared with human experts. • This automated segmentation method can be wildly applicable. [ABSTRACT FROM AUTHOR]

Coronary vasomotor dysfunction, comprising endotypes of coronary spasm and/or impaired microvascular dilatation (IMD), is common in patients with angina and no obstructive coronary arteries (ANOCA). However, there are discrepant reports regarding the prevalence of these endotypes. The objective of this study was to determine the prevalence of coronary vasomotor dysfunction in patients with ANOCA, underlying endotypes, and differences in clinical characteristics. Prospective registry of patients with ANOCA that underwent clinically indicated invasive coronary function testing (CFT), including acetylcholine spasm testing (2–200 μg) to diagnose coronary spasm, and adenosine testing (140 μg/kg/min) to diagnose IMD, defined as an index of microvascular resistance ≥25 and/or coronary flow reserve <2.0. Of the 111 patients that completed CFT (88% female, mean age 54 years), 96 (86%) showed vasomotor dysfunction. The majority 93 (97%) had coronary spasm, 63% isolated and 34% combined with IMD. Isolated IMD was rare, occurring in only 3 patients (3%). Hypertension was more prevalent in patients with vasomotor dysfunction compared to those without (39% vs. 7%, p = 0.02). Obesity and a higher severity of angiographic atherosclerotic disease were more prevalent in patients with coronary spasm compared to those without (61% vs. 28%; 40% vs. 0%, respectively, both p < 0.01). No differences in angina characteristics were observed between patients with and without vasomotor dysfunction or between endotypes. Coronary vasomotor dysfunction is highly prevalent in patients with ANOCA, especially epicardial or microvascular vasospasm, whereas isolated IMD was rare. Performing a CFT without acetylcholine testing should be strongly discouraged. Patients with signs and symptoms of Angina and No Obstructive Coronary Artery Disease and the diagnostic yield of a Coronary Function Test. CFR = coronary flow reserve; IMR = index of microvascular resistance. [Display omitted] [ABSTRACT FROM AUTHOR]

Patients with signs and symptoms suggestive of myocardial infarction and non-obstructive coronary arteries are at increased risk of adverse events. The aim of this study was to investigate the predictive role of renal function in troponin-positive patients with non-obstructive coronary arteries. A total of 564 troponin-positive patients with non-obstructive coronary arteries at coronary angiography and available baseline creatinine levels were stratified according to baseline renal function (normal/stage 1: estimated glomerular filtration rate [eGFR] >90 ml/min/1.73m2, stage 2: 60 to 89 ml/min/1.73m2, stage 3: 30 to 59 ml/min/1.73m2, and stage 4: <30 ml/min/1.73m2). The primary outcome measure was mortality at a median follow-up of 100 [12–380] days. A total of 73 (12.9%), 195 (34.6%), 231 (41.0%), and 65 (11.5%) patients were in the normal/stage 1, stage 2, stage 3, and stage 4 renal dysfunction groups. With progressive renal impairment, patients were older, more frequently presented with established coronary or peripheral artery disease, and had an increased prevalence of cardiovascular risk factors. Cumulative mortality increased with progressive renal dysfunction (normal/stage 1: 0.0%, stage 2: 3.6%, stage 3: 12.1%, and stage 4: 32.3%, log rank p < 0.001). A 10 ml/min/1.73m2 incremental decrease in eGFR was associated with an adjusted HR for mortality of 1.43 (95% CI 1.20–1.72, p < 0.001). Renal impairment was associated with mortality in patients presenting with elevated cardiac troponin and non-obstructive coronary arteries. Hence, renal function should be incorporated into the risk stratification of these patients. • Patients with MINOCA are at increased risk of adverse events. • Renal impairment was associated with mortality in patients with MINOCA. • Renal function should be incorporated into the risk stratification in MINOCA. [ABSTRACT FROM AUTHOR]

We explored the association of epicardial fat volume (EFV) with coronary plaque characteristics, coronary artery calcification (CAC) score, coronary stenosis, lesion-specific ischemia in patients with known or suspected coronary artery disease (CAD). 88 controls and 221 patients were analyzed in the study. High-risk plaque was defined as existing≥2 features, including positive remodeling, low attenuation, napkin-ring sign and spotty calcification. EFV, CAC score was measured. The severity of coronary stenosis was quantified using Gensini score. CT-FFR was performed in three major coronary arteries, with a threshold of ≤0.8 considered the presence of ischemia. Univariate and multivariate regression was used to evaluate the association of EFV with CAD, palque characteristics, CAC score, Gensini score, and lesion-specific ischemia derived from CT-FFR. Median EFV was 104.97 cm3 (85.47–136.09) in controls and 129.28cm3 (101.19–159.44) in patients (P < 0.001). Logistic regression analysis revealed a significant association of EFV with CAD even after adjusting for confounding factors (P < 0.05). At linear regression analysis, EFV was significantly correlated with high-risk plaque and lesion-specific ischemia, but not with non-calcified plaque, mixed plaque, calcified plaque, CAC score and Gensini score (P ≥ 0.05). We found that EFV was associated with CAD, suggesting that it may be a promising marker of CAD. EFV was also correlated with high-risk plaque and lesion-specific ischemia, indicating that EAT was likely to be involved in myocardial ischemia and had the potential to definite patients' risk profile. • EFV was associated with adverse plaque characteristics and lesion-specific ischemia in patients with known or suspected CAD. [ABSTRACT FROM AUTHOR]

Based on 12‑lead electrocardiogram (ECG) findings, myocardial infarction (MI) patients are dichotomized to ST-elevation MI (STEMI) and non ST-elevation MI (NSTEMI) in terms of management strategy. NSTEMI patients are increasing in numbers worldwide, among which an approximately 30% are associated with a total occlusion of a coronary artery. This review summarizes recent evidence in epidemiology, clinical, laboratory, ECG and prognostic characteristics of this NSTEMI sub-group. Patients with a diagnosis of NSTEMI and a total occluded coronary artery (TOCA) represent a sub-group of NSTEMI patients with total occlusion of coronary arteries and associated high-risk that are frequently not managed according to a STEMI-like pathway. The present review echoes a call for action in changing our everyday clinical practice. Therefore, we propose a new triage algorithm by which recognition of high-risk features in NSTEMI patients is central in order to identify STEMI 'equivalents' among NSTEMI patients in terms of similar pathology and high-risk who may benefit from immediate invasive strategy (<2 h). • NSTEMI patients in general and NSTEMI with TOCA (30%) are increasing in numbers • NSTEMI with TOCA have myocardium in jeopardy and similar poor prognosis with STEMI • Current triaging practices lack the sensitivity to identify "high-risk" NSTEMI • NSTEMI with TOCA would benefit from an immediate invasive strategy [ABSTRACT FROM AUTHOR]

The long-term prognostic utility of coronary calcification and coronary artery disease on computed tomography coronary angiography (CTCA) in remote Indigenous and non-Indigenous Australians is not known. Consecutive patients undergoing CTCA from 2013 to 2017 in Central Australia were followed-up for major adverse cardiovascular events (MACE). 347 patients were included (50 ± 12 years; 47% female; 39% Indigenous). 172 (50.0%) exhibited coronary calcification. CTCA demonstrated no coronary artery disease (CAD) in 137 (39.5%), non-obstructive CAD in 149 (42.9%), and obstructive CAD in 61 (17.6%) patients. Although Indigenous ethnicity was associated with coronary calcification and baseline CAD in age- and gender-adjusted models, this association was non-significant after accounting for comorbidities. Over 4.6 years (IQR 3.52–5.68) of follow-up, MACE incidence rates per 100 person-years were 2.92 (CI 1.92–4.44) and 0.48 (CI 0.18–1.27) in those with and without calcification respectively (p = 0.001), and 0.15 (CI 0.02–1.09), 1.32 (CI 0.69–2.54), and 6.23 (CI 3.81–10.16) in patients with no, non-obstructive, and obstructive CAD respectively (p < 0.001). Coronary calcification and obstructive CAD were associated with 5-fold (HR 5.25, 95% CI 1.66–16.59, p = 0.005) and 6-fold (HR 6.35, 95% CI 2.70–14.89, p < 0.001) greater hazards of MACE respectively in multivariable models, with no significant interaction by ethnicity in these associations seen. The prognostic value of coronary calcification and CAD on CTCA amongst remote Indigenous individuals appears similar to that seen in non-Indigenous populations. Our data suggest that coronary artery calcium scoring and CTCA can be used to risk-stratify in remote settings where a normal study is associated with an excellent prognosis for at least two years. • Computed tomography coronary angiography (CTCA) is increasingly used to risk-stratify in clinical practice. • The long-term prognostic utility of CTCA has not been assessed in remote Indigenous populations. • A normal CTCA conferred an excellent 2 year prognosis for remote Indigenous and non-Indigenous individuals. • CTCA may be a useful tool to mitigate the challenges of healthcare delivery in remote Indigenous populations. [ABSTRACT FROM AUTHOR]

To assess the prognostic implications of cardiac magnetic resonance imaging (CMR) in patients with clinical suspicion of myocardial infarction with non-obstructed coronary arteries (MINOCA). A total of 145 patients (58 ± 15 years, 97 men) were retrospectively enrolled in this single-center, longitudinal observational study. All patients underwent CMR including cine, edema-sensitive, and late gadolinium enhancement acquisitions, within a median of 3 days after cardiac catheterization. Follow-up was performed by medical records chart review and phone interviews; the median follow-up time was 4.2 years. The primary endpoint was defined as a combination of death, stroke, new onset of congestive heart failure, recurrent hospitalization, or the need for an invasive cardiac procedure. In 143 (98.6%) cases, CMR revealed the following cardiac pathologies: myocarditis (n = 48, 33.1%), structural cardiomyopathies (n = 40, 27.6%), "true" myocardial infarction (n = 22, 15.1%), hypertensive heart disease (n = 19, 13.1%), and Tako-Tsubo cardiomyopathy (n = 14, 9.7%). Only two patients (1.4%) had a normal CMR examination. There were significant prognostic differences between different etiologies, e.g. myocarditis and Tako-Tsubo cardiomyopathy had a more favorable prognosis then structural cardiomyopathies. Age, end-diastolic volume index and time-to-CMR showed significant association with the primary endpoint in multi-variate Cox regression. CMR performed early after the onset of clinical symptoms allows discrimination between acute myocardial injury from "true" MINOCA in patients presenting with chest pain and elevated cardiac biomarkers, thereby helping to identify the underlying pathology in suspected MINOCA and allowing risk stratification based on the established diagnosis. Furthermore, CMR parameters allow for improved prediction of adverse events compared to clinical and laboratory parameters. • CMR is a powerful tool in suspected MINOCA as it identifies the underlying disease in the vast majority of cases. • CMR-based diagnosis enables risk stratification of patients. • CMR parameters allow for improved prediction compared to conventional approaches. [ABSTRACT FROM AUTHOR]

To assess the effect of pharmacological therapy on long-term prognosis of patients with MINOCA. In this retrospective multicentre cohort study involving 9 Hub Hospitals across Italy we enrolled consecutive patients 18 years and older with diagnosis of MINOCA discharged from 1st March 2012 to 31st March 2018. Data on baseline characteristics and pharmacological therapy at discharge (ACEI/ARB, angiotensin-converting enzyme inhibitors/angiotensin receptor antagonists; ASA, acetylsalicylic acid; beta-blockers; CCB, calcium-channel blockers; DAPT, dual anti-platelet therapy; statins), were collected systematically. The primary endpoint (PE) of the study was a composite of all cause death or acute myocardial infarction or acute coronary syndrome or heart failure leading to hospitalization or stroke. A total of 621 patients were included (mean [SD] age 65.1 [13.9] years; 344 [55.4%] female), of whom 106 (17.1%) experienced PE, including 27 patients (4.3%) who died. Multivariable analysis, after correction for all baseline differences, showed a significant association between pharmacological therapy at discharge and an increased risk of PE for aspirin (HR[95%CI] = 2.47[1.05–5.78], adjusted p = 0.04), whereas beta-blockers were associated with a significant benefit (HR[95%CI] = 0.49 [0.31–0.79], adjusted p = 0.02). The use of beta-blockers was significantly associated to a less frequent occurrence of adverse outcomes at long-term follow-up among patients with MINOCA, whereas ASA displayed a potentially harmful impact on prognosis. The findings in the study may be relevant for the design of future studies which should take into account possible heterogeneity among MINOCA patients. • The optimal pharmacological therapy in patients with MINOCA is uncertain. • Beta-blockers are significantly associated to a reduced risk of adverse events. • Acetylsalicylic acid displays a potentially harmful impact on outcomes. • Heterogeneity among MINOCA patients could affect the prognostic impact of therapy. [ABSTRACT FROM AUTHOR]

Background Immediate and long-term functional outcomes after percutaneous treatment of small vessel disease (SVD) with drug-coated balloon (DCB) versus drug-eluting stent (DES) remain unknown. The study sought to investigate whether treatment of de novo SVD with DCB yields similar functional results compared with DES, as judged with angiography-based quantitative flow ratio (QFR). Methods and results QFR was measured at pre-procedural, post-procedural and 9-month angiography in all available subjects from the non-inferiority RESTORE SVD China trial, in which patients were randomized to Restore DCB (n = 116) or Resolute DES (n = 114) study arms. Primary outcome of this analysis was 9-month QFR. Pre-procedural, post-procedural and 9-month QFR was performed in 84.8% (195/230), 83.0% (191/230) and 93.8% (181/193) cases, respectively. At 9 months, the QFR of DCB showed no significant difference to DES (0.88 ± 0.23 vs. 0.92 ± 0.12, p = 0.12). Both 9-month QFR and the QFR difference between post-procedure and 9-month follow-up were correlated with angiographic percentage of diameter stenosis and late loss, and predictive of 2-year clinical outcome. Conclusions Treatment of coronary SVD with DCB resulted in similar 9-month functional results compared with DES. This study provides evidences to the value of QFR as a mean of evaluating device performance after coronary revascularization. Clinical trial registration URL: https://www.clinicaltrials.gov ; ClinicalTrial.gov: Identifier: NCT02946307. • Percutaneous revascularization in SVD with DCB resulted in a similar functional outcome with DES at 9-month follow-up. • Performing QFR in small vessels is feasible and useful as a mean of evaluating device performance. • Future studies may investigate QFR or QFR loss in combination with % diameter stenosis or late lumen loss as a surrogate endpoint. [ABSTRACT FROM AUTHOR]

Spontaneous coronary artery dissection (SCAD) is increasingly recognized as an important cause of myocardial infarction (MI). Currently there is little knowledge about prognostic factors for unfavorable outcome at long term follow-up; furthermore, there is also little knowledge about the genetics of these patients. This observational and retrospective study describes long-term cardiovascular outcomes of a population affected by SCAD and assesses predictors of recurrent de novo SCAD and major adverse cardiovascular events (MACE). Furthermore, a correlation between genotype and adverse events at follow-up was sought. Baseline characteristics, angiographic features, use of medication and long-term cardiovascular events were systematically ascertained between 2000 and 2019. Next generation sequencing was performed with a panel consisting of twenty genes of interest. Variants found were filtered based on their frequency and only frequencies <1% in the general population were considered as "positive". Seventy patients were enrolled and followed for a median time of 39.1 months. Median age was 52 years and the majority were women (86%). Use of hormone therapy (HT) (OR 3.64, p = 0.041) and presence of malignant ventricular arrhythmias (VAs) at onset (OR 7.03, p = 0.0073) were associated with a greater risk of recurrent de novo SCAD. Proximal type SCAD (OR 8.47, p < 0.0001) and presence of VAs at onset (OR 9.97, p = 0.047) were associated with a greater risk of MACE. A potential SCAD-associated mutation was detected in 27 patients (44%); 6 patients (22%) defined as genetically "positive" developed MACE vs. 2 patients (6%) defined as "negative" (p = 0.06 at univariate analysis). MACE at follow-up is reached earlier in genetically positive patients (7.9 vs. 42.5 months). use of HT and VAs at SCAD onset are prognostic factors for recurrent de novo SCAD. Proximal SCAD site and VAs at SCAD onset were prognostic factors for MACE. Analysis by molecular genetics seems to be a promising tool for the possible additional role it could play in MACE prediction. • The strong point of our work is represented from two new cornerstones for better understanding this disease. • First, we have shown that there are several prognostic factors that can predict both recurrent de novo SCAD (use of hormonal therapy and ventricular arrhythmias) and major adverse cardiovascular events (MACE) (ventricular arrhythmias and proximal coronary site of the lesion at the first event). • Second, we have highlighted how there may be a relationship between MACE development and genetic mutations sought through next generation sequencing. [ABSTRACT FROM AUTHOR]

Although the adverse events of pathologic Vieussens' arterial ring (VAR) have been reported, it is difficult to determine optimal clinical management. Thus, we hypothesized that the luminal diameter ratio of VAR obtained from coronary computed tomography angiography (CCTA) could be used as a clinical tool to inform appropriate patient management. A total of 29 patients with pathologic VAR were retrospectively recruited for this study. The VAR luminal diameter ratio was defined as a quotient of VAR fistula divided by the orifice of RCA or LAD, based on which, patients were divided into small fistula group and large fistula group. The AUC, sensitivity, specificity, positive and negative predictive values were obtained from ROC curve. The cutoff value of the VAR luminal diameter ratio was calculated and assessed during the follow-up. The VAR luminal diameter ratio of fistula/RCA orifice was 0.505 ± 0.098 in small fistula group and 1.020 ± 0.150 in large fistula group. The VAR luminal diameter ratio of fistula/LAD orifice was 0.507 ± 0.123 in small fistula group and 1.039 ± 0.151 in large group. The value was correlated with the choice of the treatment (r = 0.643 p < 0.01, r = 0.627 p < 0.01). The AUC, sensitivity, specificity, positive and negative predictive values were 0.803, 54.5%, 100%, 100% and 78.3% of the fistula/RCA orifice ratio and 0.833, 63.64%, 94.44%, 87.5% and 81.0% of the fistula/LAD orifice ratio, respectively. The cutoff values of both fistula/RCA orifice and fistula/LAD orifice ratios were 0.676. The VAR luminal diameter ratio may be a valuable index to determine appropriate treatment for patients with pathologic VAR. • The VAR luminal diameter ratio is a valuable index in determining pathologic VAR treatment. • The VAR luminal diameter ratio is associated with VAR-pulmonary fistula hemodynamical change. • VAR patients with a VAR luminal diameter ratio higher than 0.676 should be considered for earlier intervention in the pathogenesis of disease. [ABSTRACT FROM AUTHOR]