Abstract 16479: A Comparison of Rates of Significant Coronary Artery Disease Found on Invasive Coronary Angiography in Patients Who Underwent Nuclear Stress Testing or CT Coronary Angiography as a Workup for Acute Coronary Syndrome

Introduction: Chest pain syndromes are one of the most common causes of hospital admission. The correct diagnosis as cardiac [acute coronary syndromes (ACS)] with associated morbidity and mortality, or non-cardiac has important medical and legal consequences. Appropriate and timely diagnosis of these conditions is essential, yet limited literature exists comparing two common diagnostic tools, CT coronary angiography (CTCA) and nuclear stress testing (NST) in the acute inpatient setting. Methods: We conducted a retrospective analysis to determine rates of ischemia and intervention needed in patients without ischemic cardiac history, who were evaluated for ACS with NST or CTCA and who subsequently underwent invasive coronary angiography (IA) with iFR and angioplasty as appropriate. Results: We identified 121 CTCA cases and 45 NST cases. There were no significant difference in age, rates of hypertension, diabetes mellitus, renal disease, aspirin or statin use. However, there were more male patients in the CTCA group and higher mean GRACE scores and creatinine on admission in the NST group. Patients who underwent CTCA were found to have higher rates of significant coronary artery disease defined as iFR < 0.9 or ≥70% stenosis on IA (63% vs 44%), and shorter mean length of stay (4.5 vs 6.5 days). Rates of artifact were higher in the NST group (64% vs 24%) and CTCA demonstrated higher specificity (90% vs 28%) and greater positive predictive value (92% vs. 41%) than NST. (Table 1) Conclusions: Our study found that CTCA compared to NST in admitted patients being evaluated for chest pain syndromes was associated with lower rates of reported artifact, shorter length of stay, higher rates of IA confirmed significant coronary disease, and higher specificity and positive predictive value for needed intervention when evaluated with IA. While limited by its single center analysis, our study demonstrates the potential value of CTCA in a real-world population which merits further study.

Looking for ischemia in patients with stable atypical chest pain: useful or useless?

Introduction Patients with stable atypical chest pain (SACP) represent more than half of those with chest pain who require an outpatient evaluation. It's not clear if in these patients the prognosis is linked more to the optimal control of risk factors and to the research and treatment of any unfavorable anatomical alterations (common trunk obstruction, proximal involvement of VAT, multivessel disease with systolic dysfunction of the left ventricle) rather than to ischemia assessment with functional tests. Methods In the past 20 years we have evaluated the lifestyles of 40,422 outpatient patients. 9% (3,638) had a history of stable chest pain with no history of previous cardiovascular events. In the 1,322 patients (36%) with non-anginal chest pain, no diagnostic examination was performed after the electrocardiogram (ECG) and the echocardiogram. 462 patients (13%) had typical chest pain, and 422 of them performed a coronary angiography. The other 1,854 (51%) patients with SACP underwent functional testing for ischemia (exercise ECG, ecostress, nuclear stress testing). They were also stratified according to the presence of 4 main modifiable lifestyles (cigarette smoking, diet, physical activity, obesity) and the 3 main cardiovascular risk factors (hypercholesterolemia, hypertension, diabetes). Results In the SACP group, the search for ischemia was positive in 192 patients (10.4%); 178 of them underwent coronary angiography, which demonstrated the presence of lesions with indication to revascularization to improve the prognosis, according to the ESC 2018 guidelines (Class IA), in 21 patients (11.7%). In the remaining 1,662 patients functional tests were negative. We performed one-year follow-up. Major coronary events (fatal and non-fatal infarction, sudden death) occurred in 22 patients (1.3%) with negative stress tests and at least 3 risk factors or bad lifestyles (especially smoking, diabetes, high LDL). In patients with positive stress tests, there were 3 events, (1.5%), that occurred among patients with at least 3 risk factors, too. No events occurred in patients with fewer than 3 risk factors or lifestyles in either group. Conclusions In patients with SACP and negative functional test the risk of major coronary events remains 1.3% at 1 year of follow-up; the events occurr in patients with 3 or more factors or lifestyle at risk (especially smoking, diabetes, elevated LDL). The prognosis is similar to those with positive ischemia research. The improvement of the outcomes should be entrusted more to a close control of the risk factors, to an optimal improvement of the lifestyles and to an anatomical evaluation (coronary CT) for the evaluation of those lesions that improve the prognosis rather than the search for ischemia which appears futile from a diagnostic and prognostic point of view as well as a source of economic waste. Funding Acknowledgement Type of funding source: None

Age, Sex, and Gene Expression Score identifies a symptomatic, nondiabetic male patient as being at high risk of obstructive coronary artery disease

In October 2015, a 74-year-old Caucasian male patient (past medical history of hyperlipidemia, paroxysmal atrial fibrillation, hypertension, and hypothyroidism) presented to the cardiologist for follow-up outpatient evaluation of exertional chest pain. The patient had recently been seen at the Emergency Department for the same complaint. At that time, the patient’s cardiac markers, EKG, and pharmacological nuclear stress testing were all reported as normal. At presentation to the cardiologist, the patient’s physical examination findings were unremarkable. Over the course of the following year, repeat electrocardiograms and myocardial perfusion imaging studies demonstrated no evidence of ischemia. Despite the persistence of symptoms, the patient was reluctant to undergo invasive testing. The cardiologist ordered a simple blood test: the Age, Sex, and Gene Expression Score, which provides the current likelihood of obstructive coronary artery disease in nondiabetic patients. Based on the high Age, Sex, and Gene Expression Score result, the patient underwent invasive coronary angiography and a 98% stenotic lesion in the proximal left anterior descending artery was discovered. A drug-eluting coronary stent was placed and resulted in the complete resolution of the patient’s symptoms.

Abstract 404: A High Dose Olive Oil, Polyphenol, and Lectin Limited Diet Reverses and/or Stabilizes Advanced Coronary Artery Disease

Introduction: Coronary Artery Disease (CAD) is thought to be progressive; standard treatment protocols call for instituting a low fat/low cholesterol diet program, exercise, and lipid lowering agents. This results in an approximate 30-40% new event rate in 5 yrs. We evaluated our treatment strategy to reverse CAD with The Corus Score (CS) (Cardiodx, Redwood City, Ca), proven to quantify coronary artery obstructive plaque by the expression of 23 genes. Methods: Based upon using a Lectin-limited diet to prevent/reverse Metabolic Syndrome and CAD, we have enrolled and followed 800 pts (aged 42-89 yrs) with known CAD, defined as previous MI, stent, CABG, or positive stress test/angiogram, positive CS greater than 30, into a physician coached program, which reduces grains, legumes, nightshades, seeded vegetables, Casein A1 milk, (the all lectin containing food groups),and fruits; emphases consumption a liter of olive oil/wk, large amts of green vegetables, and 4 oz amts of proteins, avoiding commercial poultry (Matrix Protocol). All Apo E 4 genotypes avoided animal fats and cheeses. Pts were instructed to take 4,000 mg of high DHA fish oil, 200mg of Grape Seed Extract, and 25 mg of Pycnogenol per day, and consume polyphenol rich coffee and/or teas and 1 oz dark chocolate/day. Diets/supplements were individualized based on results of Advanced Cardiovascular Risk Markers (ACRM), which were sent to two core labs. Yearly assessment of CAD severity was measured by Corus Score (possible range 1-40). Any score above 30 was assessed by Nuclear Stress testing. Results: Pts have been followed for 1.5 to 6 years (mean 4.5 yrs). Only 6/800 pts (0.5%) have received a new stent, all 6 had rising Corus scores: two also had a rising Lp-PLA2, 2 had rising Cardiac Troponin I levels; one pt required CABG: . There have been no MI’s, unstable angina. Corus scores at baseline decreased from 34+/-4 (range 6-36) to 24+/-3, P<0.01. Only 64/800 pts (8%) had a rise in Corus scores/ 736/800 pts’ CS declined or remained stable (92%). Only 6/64 Corus scores had positive Stress tests. Conclusions: Simple Nutrigenomic-based dietary interventions, based upon ACRM's and Corus Scores, represents a quantum leap forward in preventing/modifying Cardiovascular events in known CAD patients.