Prognostic Significance of Targeted Magnetic Resonance Coronary Angiography to Predict Cardiac Events in Patients with Known or Suspected Coronary Artery Disease

Background: Magnetic resonance coronary angiography (MRCA) is one of the most promising tools for noninvasive imaging of coronary arteries without radiation exposure or contrast media administration. However, knowledge about the prognostic value of MRCA is limited. Materials and Methods: The present study included 389 patients with known or suspected coronary artery disease (CAD) underwent clinical cardiac magnetic resonance (CMR) including MRCA imaging. The presence of a significant coronary artery stenosis was defined by visual estimation of ≥50% diameter reduction using targeted MRCA images. Patients were followed up for hard cardiac events (cardiac death or non-fatal myocardial infarction) and major adverse cardiac events (MACE) which also included hospitalization for heart failure and late revascularization (>180 days after the CMR study). Results: The average age was 68±11 years and 48% were male. One hundred and thirty-nine patients had significant stenosis on MRCA. During a median follow-up period of 53.9 months, 23 hard cardiac events and 52 MACE, occurred. Patients with significant coronary artery stenosis had higher rates of hard cardiac events (annual event rate 3.12% versus 0.56%, HR 5.52, 95% CI 2.17 to 14.01, p<0.001) and MACE (annual event rate 6.44% versus 1.83%, HR 3.49, 95% CI 1.98 to 6.14, p<0.001) than those without significant stenosis. Multivariable analyses identified significant coronary artery stenosis as an independent predictor of hard cardiac events (HR 3.35, 95% CI 1.13 to 9.96, p=0.03) and MACE (HR 2.00, 95% CI 1.02 to 3.90, p=0.04). MRCA presented an incremental prognostic value over clinical factors, left ventricular ejection fraction, and myocardial scarring to predict hard cardiac events (p=0.03). Conclusion: Targeted MRCA demonstrated independent and incremental prognostic values to predict future cardiac events in patients with known or suspected CAD. Keywords: Cardiac magnetic resonance imaging; Coronary artery disease; Magnetic resonance coronary angiography; Prognosis

Effect of Significant Coronary Artery Stenosis on Prognosis in Patients with Vasospastic Angina: A Propensity Score-Matched Analysis

Vasospastic angina (VA) is a functional disease of the coronary artery and occurs in an angiographically normal coronary artery. However, it may also occur with coronary artery stenosis. We investigated the effect of coronary artery stenosis on clinical outcomes in VA patients. Study data were obtained from a prospective multicenter registry that included patients who had symptoms of VA. Patients were classified into two groups according to presence of significant coronary artery stenosis. Among 1920 patients with VA, 189 patients were classified in the “significant stenosis” group. The one-year composite clinical events rate was significantly higher in the significant stenosis group than in the “no significant stenosis” group (5.8% vs. 1.4%, respectively; p < 0.001). Additionally, the prevalence of ACS was significantly greater in the "significant stenosis" group (4.8% vs. 0.9%, respectively; p < 0.001). After propensity score matching, the adverse effects of significant stenosis remained. In addition, significant stenosis was independently associated with a 6.67-fold increased risk of ACS in VA patients. In conclusion, significant coronary artery stenosis can increase the adverse clinical outcomes in VA patients at long-term follow-up. Clinicians should manage traditional risk factors associated with atherosclerosis and control vasospasm as well as reduce the burden of atherosclerosis.

Prognostic Significance of Targeted Magnetic Resonance Coronary Angiography to Predict Cardiac Events in Patients with Known or Suspected Coronary Artery Disease

Background Magnetic resonance coronary angiography (MRCA) is one of the most promising tools for noninvasive imaging of coronary arteries without radiation exposure or contrast media administration. However, knowledge about the prognostic value of MRCA is limited.Methods The study included 389 patients with known or suspected coronary artery disease (CAD) who underwent clinical cardiac magnetic resonance (CMR) including MRCA imaging. The presence of significant coronary artery stenosis was defined by visual estimation of ≥50% diameter reduction using targeted MRCA images. Patients were followed up for hard cardiac events (cardiac death or non-fatal myocardial infarction) and major adverse cardiac events (MACE) that also included hospitalization for heart failure and late revascularization (>180 days after the CMR study).Results Average age was 68±11 years and 48% were male. One hundred and thirty-nine patients had significant stenosis on MRCA. During a median follow-up period of 53.9 months, 23 hard cardiac events and 52 MACE occurred. Patients with significant coronary artery stenosis had higher rates of hard cardiac events (annual event rate, 3.12% versus 0.56%; HR 5.52; 95% CI 2.17-14.01; p<0.001) and MACE (annual event rate, 6.44% vs. 1.83%; HR 3.49; 95% CI 1.98-6.14; p<0.001) than those without significant stenosis. Multivariate analyses identified significant coronary artery stenosis as an independent predictor of hard cardiac events (HR 3.35; 95% CI 1.13-9.96; p=0.03) and MACE (HR 2.00; 95% CI 1.02-3.90; p=0.04). MRCA presented an incremental prognostic value over clinical factors, left ventricular ejection fraction, and myocardial scarring to predict hard cardiac events (p=0.03).Conclusion Targeted MRCA demonstrated independent and incremental prognostic values to predict future cardiac events in patients with known or suspected CAD.

Rapid atrial fibrillation increases cardiac biomarkers: decision to perform coronary angiography based on novel high-sensitivity Troponin I peak

Funding Acknowledgements Type of funding sources: None. Background Since January 2018 the availability of high sensitivity Troponin I (hsTnI) has improved ischemia diagnosis. In patients with rapid atrial fibrillation (AF), the decision to undergo coronary angiography is usually due to elevated cardiac biomarkers. However, evidence to support the rentability of this approach is sparse. Purpose Evaluate if hsTnI in patients with rapid AF and elevated cardiac biomarkers has a good discriminative power to predict a positive coronary angiography. Methods We retrospectively studied consecutive patients admitted to the emergency department (ED) between January 2018 and December 2019 with rapid AF that underwent coronary angiography and had multiple hsTnI values obtained. We analysed risk factors, initial and peak hsTnI, time from ED admission to peak hsTnI and ST-T segment abnormalities (ST depression and/or T wave inversion). We evaluated the presence of significant coronary artery stenosis with the need of revascularization at coronary angiography. Univariable and multivariable analysis was performed to obtain the Odds Ratio (OR, 95% CI, p-value) for significant coronary artery disease (CAD). Receiver operator characteristics (ROC) curve and area under the curve (AUC) were obtained to determine the discriminative power of peak hsTnI as predictor of a positive coronary angiography. Optimal cut-point value was obtained (Youden index) and patients were divided according to this value. Results From 1407 patients admitted to the ED with rapid AF, 30 patients, 60% male, median age 74 (IQR 61.25-80.75) years, were submitted to coronary angiography. Significant coronary artery stenosis was present in 17 (57%) patients. Age, ST-T segment abnormalities and peak hsTnI were predictors of significant CAD, respectively 1.203, 1.064-1.361, 0.003; 25.00, 3.522-177.477, 0.001; and 1.000, 1.000-1.001, 0.015. Optimal cut-point value for predicting the presence of significant coronary artery stenosis at coronary angiography was a peak hsTnI of 359 pg/mL (AUC 0.869, p-value 0.001, 95% CI 0.742-0.995). The two groups with hsTnI &lt; 359 and hsTnI &gt;359 differed in age and ST-T segment abnormalities (see Table). After adjustment, peak hsTnI &gt;359 pg/mL was the only independent predictor of significant CAD (23.894, 1.310-435.669, 0.032). Conclusion In this group of patients with rapid AF, peak hsTnI &gt;359 pg/mL was the only independent predictor of significant coronary artery disease. Therefore, those patients should undergo coronary angiography. Abstract Figure.

Initially elevated troponin I in rapid atrial fibrillation should lead to coronary angiography

Funding Acknowledgements Type of funding sources: None. Background In patients admitted to the emergency department (ED) with rapid atrial fibrillation (AF), the decision to undergo coronary angiography is usually due to elevated cardiac biomarkers. However, a study evaluating the rentability of this approach has never been done. Purpose Evaluate the predictors of a positive coronary angiography performed in patients with rapid AF and elevated cardiac biomarkers. Methods We retrospectively studied patients admitted to the ED between January 2016 and December 2018 with rapid AF who have undergone coronary angiography. We analysed symptoms, risk factors, initial value, peak value and curve of troponin I (TnI) and ST-T segment abnormalities. We evaluated the presence of significant coronary artery stenosis with the need of revascularization at coronary angiography and we used logistic regression to assess the predictors of a positive result. Results From 2265 patients admitted to the ED with rapid AF, 46 patients, 60.9% (28) male, median age 73 (IQR 14.75) years, were submitted to coronary angiography. Significant coronary artery stenosis was present in 24 (52.2%) patients. Regarding cardiovascular risk factors, 39 (85.6%) patients had hypertension, 15 (32.6%) had type 2 diabetes mellitus, 36 (78.3%) had dyslipidaemia, 25 (54.3%) were obese or overweight and 12 (26.1%) had a previous history of CAD. Twenty-eight (60.9%) patients presented with chest pain and 27 (58.7%) had ST-T segment abnormalities. Of note, in 17 (37.0%) cases high-sensitivity TnI was measured. In univariable analysis, ST-T segment abnormalities, the presence of typical TnI curve and an elevated initial TnI predicted the presence of significant CAD in coronary angiography. In multivariable analysis, an initial TnI value above the upper reference limit (URL) was the only independent predictor of significant CAD in coronary angiography. Conclusion In this group of patients with rapid AF an initial elevated TnI was the only independent predictor of the presence of significant CAD. Therefore, maybe it would be advisable to perform coronary angiography in these patients. Without CADWith CADUnivariate analysisOR (95% CI), p-valueMultivariate analysisOR (95% CI), p-valueAge in years, median (IQR)69 (15)77.5 (17)1.045 (0.988-1.106), 0.1270.967 (0.882-1.062), 0.484Type 2 diabetes mellitus, n (%)5 (23.8)10 (41.7)2.286 (0.629-8.313), 0.2095.865 (0.566-60.806), 0.138ST-T segment abnormalities, n (%)8 (36.4)19 (79.2%)6.650 (1.788-24.730), 0.0055.338 (0.491-58.063), 0.169Typical TnI curve, n (%)10 (52.6)20 (90.9)9.000 (1.628-49.756), 0.01217.900 (0.475-674.480), 0.119Elevated initial TnI, n (%)10 (45.5)18 (75.0)3.600 (1.033-12.542), 0.04415.167 (1.363-168.778), 0.027Peak TnI elevation &gt;2 times URL, n (%)11 (50.0)18 (75.0)3.000 (0.863-10.428), 0.0840.169 (0.005-5.298), 0.312

Relationship between Whole Blood Viscosity and Lesion Severity in Coronary Artery Disease

Objective This article investigates the relationship of fractional flow reserve (FFR) with whole blood viscosity (WBV) in patients who were diagnosed with chronic coronary syndrome and significant stenosis in the major coronary arteries and underwent the measurement of FFR. Material and Method In the FFR measurements performed to evaluate the severity of coronary artery stenosis, 160 patients were included in the study and divided into two groups as follows: 80 with significant stenosis and 80 with nonsignificant stenosis. WBVs at low shear rate (LSR) and high shear rate (HSR) were compared between the patients in the significant and nonsignificant coronary artery stenosis groups. Results In the group with FFR < 0.80 and significant coronary artery stenosis, WBV was significantly higher compared with the group with nonsignificant coronary artery stenosis in terms of both HSR (19.33 ± 0.84) and LSR (81.19 ± 14.20) (p < 0.001). In the multivariate logistic regression analysis, HSR and LSR were independent predictors of significant coronary artery stenosis (HSR: odds ratio: 1.67, 95% confidence interval: 1.17–2.64; LSR: odds ratio: 2.46, 95% confidence interval: 2.19–2.78). In the receiver operating characteristic (ROC) curve analysis, when the cutoff value of WBV at LSR was taken as 79.23, it had 58.42% sensitivity and 62.13% specificity for the prediction of significant coronary artery stenosis (area under the ROC curve: 0.628, p < 0.001). Conclusion WBV, an inexpensive biomarker that can be easily calculated prior to coronary angiography, was higher in patients with functionally severe coronary artery stenosis, and thus could be a useful marker in predicting the hemodynamic severity of coronary artery stenosis in patients with chronic coronary syndrome.

Global longitudinal strain at rest predicts significant coronary artery stenosis in patients with peripheral arterial disease

Funding Acknowledgements Type of funding sources: None. Background Critical peripheral artery disease (PAD) is expression of systemic chronic atherosclerosis, it being often associated with cardiovascular events. The assessment of global longitudinal strain (GLS) at rest by speckle tracking echocardiography could be useful to unmask significant coronary artery disease (CAD) in asymptomatic PAD patients. Purpose To determine whether resting GLS is able to predict significant coronary artery stenosis in PAD patients selected for peripheral or carotid angiography. Methods One-hundred three clinically relevant PAD patients (M/F = 76/27, age = 66.8 ± 10,2 years, 72 with significant lower limb artery stenosis and 31 with carotid artery stenosis ≥50%), asymptomatic for CAD, underwent standard echo-Doppler exam at rest, comprehensive of GLS analysis, prior peripheral and coronary angiography. Information on cardiovascular (CV) risk factors and comorbidities were collected. Patients with know CAD and previous myocardial infarction, left ventricular (LV) ejection fraction &lt; 50% and inadequate echocardiographic imaging were excluded. According to the results of coronary angiography, patients were divided in two groups: with significant coronary artery stenosis (&gt;50% of obstruction. n = 73) and without significant coronary artery lesions (n = 30). Results No intergroup difference in the prevalence of CV risk factors and comorbidities was found. Age, body mass index and blood pressure were comparable between the two groups. LV ejection fraction (59.9 ± 4.2% in patients with significant coronary stenosis vs. 60.2 ± 4.7% in those without coronary stenosis, p = 0.75) and wall motion score index (1.02 ± 0.09 vs 1.03 ± 0.09 respectively, p = 0.67) did not differ significantly. Conversely, GLS was lower in patients with significant coronary artery stenosis than in those without (21.6 ± 2.7% vs. 22.8 ± 2%, p &lt; 0.02) (Figure 1). This difference remained significant comparing the carotid subgroup with coronary stenosis vs. those without (p &lt; 0.05) whereas it did not achieve the statistical significance in patients with lower limb artery lesions (p = 0.42). Conclusion In PAD patients, GLS at rest shoes the capability in identifying patients at higher probability of significant coronary artery stenosis. This involves in particular patients with carotid artery stenosis. GLS might be helpful to select patients who need to extend the peripheral angiographic evaluation to the coronary tree.

Systemic immune-inflammation index is a novel marker to predict functionally significant coronary artery stenosis

Aim: The study aimed to investigate and compare the predictive capacity of a systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) to determine a hemodynamically significant coronary artery stenosis assessed by fractional flow reserve (FFR). Patients & methods: A total of 207 chronic coronary syndrome patients with FFR measurement were enrolled in the study. NLR, PLR and SII levels were calculated. Results: The cut-off value of the SII (620) was associated with 78.4% sensitivity and 64.0% specificity to predict a hemodynamically significant stenosis. SII level independently predicted FFR ≤0.80. Conclusion: SII is an independent predictor of functionally significant coronary stenosis detected by FFR in chronic coronary syndrome patients. SII levels can predict hemodynamically severe obstruction better than NLR and PLR.