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BACKGROUND: The clinical benefits of optical frequency domain imaging (OFDI)-guided percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) remain unclear. AIMS: We sought to compare intravascular ultrasound (IVUS)- and OFDI-guided PCI in patients with ACS. METHODS: OPINION ACS is a multicentre, prospective, randomised, non-inferiority trial that compared OFDI-guided PCI with IVUS-guided PCI using current-generation drug-eluting stents in ACS patients (n=158). The primary endpoint was in-stent minimum lumen area (MLA), assessed using 8-month follow-up OFDI. RESULTS: Patients presented with ST-segment elevation myocardial infarction (55%), non-ST-segment elevation myocardial infarction (29%), or unstable angina pectoris (16%). PCI procedural success was achieved in all patients, with comparably low periprocedural complications rates in both groups. Immediately after PCI, the minimum stent area (p=0.096) tended to be smaller for OFDI versus IVUS guidance. Proximal stent edge dissection (p=0.012) and irregular protrusion (p=0.03) were significantly less frequent in OFDI-guided procedures than in IVUS-guided procedures. Post-PCI coronary flow, assessed using corrected Thrombolysis in Myocardial Infarction frame counts, was significantly better in the OFDI-guided group than in the IVUS-guided group (p<0.001). The least squares mean (95% confidence interval [CI]) in-stent MLA at 8 months was 4.91 (95% CI: 4.53-5.30) mm2 and 4.76 (95% CI: 4.35-5.17) mm2 in the OFDI- and IVUS-guided groups, respectively, demonstrating the non-inferiority of OFDI guidance (pnon-inferiority<0.001). The average neointima area tended to be smaller in the OFDI-guided group. The frequency of major adverse cardiac events was similar. CONCLUSIONS: Among ACS patients, OFDI-guided PCI and IVUS-guided PCI were equally safe and feasible, with comparable in-stent MLA at 8 months. OFDI guidance may be a potential option in ACS patients. This study was registered in the Japan Registry of Clinical Trials (jrct.niph.go.jp: jRCTs052190093).
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Síndrome Coronario Agudo , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea , Ultrasonografía Intervencional , Humanos , Ultrasonografía Intervencional/métodos , Intervención Coronaria Percutánea/métodos , Masculino , Síndrome Coronario Agudo/terapia , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/cirugía , Femenino , Persona de Mediana Edad , Anciano , Resultado del Tratamiento , Estudios Prospectivos , Tomografía de Coherencia Óptica/métodos , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/cirugía , Angina Inestable/terapia , Angina Inestable/diagnóstico por imagen , Angina Inestable/cirugíaRESUMEN
OBJECTIVE: Coronary artery disease is one of the most common causes of disability and work loss among working-age individuals. Since the ability to return to work after cardiovascular events depends on several factors, identifying these factors can be helpful in treatment planning and effective rehabilitation. In this study, we aimed to assess the employment status and related factors one year after angiography in patients with stable angina and acute coronary syndrome and to investigate the impact of occupational factors on angiographic characteristics. METHODS: This retrospective study included 447 patients with coronary artery disease who underwent angiography between February 2020 and March 2021 at a teaching hospital. Data regarding employment status and other related variables, including the Job Content Questionnaire, were collected through medical record reviews and telephone interviews one year after hospital discharge. The participants' occupational factors and return-to-work status were then compared. RESULTS: One year after angiography, the rate of returning to work was 70%. Of these, 86.3% had resumed their previous job. Factors associated with a reduced return to work included major coronary artery involvement, a history of hypertension, lower ejection fraction, and increased hospitalization days. Occupational risk factors such as low income, longer working hours, and high job demand also decreased the likelihood of returning to employment. CONCLUSION: Various clinical and socioeconomic factors can predict the probability of returning to work after angiography in patients with coronary artery disease. Considering these factors could be useful in formulating clinical guidelines to improve employment outcomes for these patients.
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Angiografía Coronaria , Reinserción al Trabajo , Humanos , Reinserción al Trabajo/estadística & datos numéricos , Masculino , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Angiografía Coronaria/estadística & datos numéricos , Factores de Riesgo , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/rehabilitación , Anciano , Adulto , Empleo/estadística & datos numéricos , Angina Estable/diagnóstico por imagenRESUMEN
OBJECTIVES: We evaluated the ability of the assessment of regional wall motion abnormalities (RWMA) detected via transthoracic echocardiography to predict the presence of obstructive coronary artery disease (CAD) in patients presenting with acute chest pain to the emergency department. DESIGN: Prospective single-centre observational study. SETTING: Tertiary care university hospital emergency unit. PARTICIPANTS: Patients presenting to the emergency department with acute chest pain suggestive of obstructive CAD. PRIMARY OUTCOME MEASURE: The primary endpoint was defined as the presence of obstructive CAD, requiring revascularisation therapy. RESULTS: Overall, 657 patients (age 58.1±18.0 years, 53% men) were included in our study. RWMA were detected in 76 patients (11.6%). RWMA were significantly more frequent in patients reaching the primary endpoint (26.2% vs 7.6%, p<0.001). In multivariable regression analysis, the presence of RWMA was associated with threefold increased odds of the presence of obstructive CAD (3.41 (95% CI 1.99 to 5.86), p<0.001). Adding RWMA to a multivariable model of the Thrombolysis in Myocardial Infarction (TIMI) risk score, cardiac biomarkers and traditional risk factors significantly improved the area under the curve for prediction of obstructive CAD (95% CI 0.777 to 0.804, p=0.0092). CONCLUSION: RWMA strongly and independently predicts the presence of obstructive CAD in patients presenting with acute chest pain to the emergency department. TRIAL REGISTRATION: The study has been registered online (NCT03787797).
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Dolor en el Pecho , Ecocardiografía , Servicio de Urgencia en Hospital , Humanos , Masculino , Femenino , Persona de Mediana Edad , Estudios Prospectivos , Ecocardiografía/métodos , Dolor en el Pecho/etiología , Dolor en el Pecho/diagnóstico por imagen , Anciano , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/fisiopatología , Síndrome Coronario Agudo/diagnóstico por imagen , Factores de Riesgo , AdultoAsunto(s)
Angioplastia Coronaria con Balón , Angiografía Coronaria , Reestenosis Coronaria , Stents Liberadores de Fármacos , Humanos , Reestenosis Coronaria/diagnóstico por imagen , Reestenosis Coronaria/etiología , Angiografía Coronaria/métodos , Angioplastia Coronaria con Balón/métodos , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/cirugía , Síndrome Coronario Agudo/terapia , Masculino , Femenino , Materiales Biocompatibles RevestidosRESUMEN
BACKGROUND: Drug-coated balloon (DCB) angioplasty and drug-eluting stents (DES) are two widely used treatments for in-stent restenosis (ISR). Focal and non-focal types of ISR affect the clinical outcomes. The present study aims to compare DES reimplantation versus DCB angioplasty in acute coronary syndrome (ACS) patients with focal ISR and non-focal ISR lesions. METHODS: Patients with ISR lesions underwent percutaneous coronary intervention (PCI) were retrospectively evaluated and divided into DES group and DCB group. The primary endpoint was the incidence of target lesion failure (TLF) at 24 months follow up. Propensity score matching (PSM) was conducted to balance the baseline characteristics. RESULTS: For focal ISR, TLF was comparable in the DES and DCB groups at 24 months of follow-up (Before PSM, hazard ratio [HR]: 0.70; 95% confidence interval [CI]: 0.39-1.27; p = 0.244; After PSM, HR: 0.83; 95% CI: 0.40-1.73; p = 0.625). For non-focal ISR, TLF was significantly decreased in DES compared with DCB group (Before PSM, HR: 0.43; 95% CI: 0.29-0.63; p < 0.001; After PSM, HR: 0.33; 95% CI: 0.19-0.59; p < 0.001), which was mainly attributed to the lower incidence of clinically indicated target lesion revascularization (CD-TLR) (Before PSM, HR: 0.39; 95% CI: 0.26-0.59; p < 0.001; After PSM, HR: 0.28; 95% CI: 0.15-0.54; p < 0.001). CONCLUSIONS: The clinical outcomes for DES and DCB treatment are similar in focal type of ISR lesions. For non-focal ISR, the treatment of DES showed a significant decrease in TLF which was mainly attributed to a lower incidence of CD-TLR.
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Síndrome Coronario Agudo , Angioplastia Coronaria con Balón , Angiografía Coronaria , Reestenosis Coronaria , Stents Liberadores de Fármacos , Humanos , Masculino , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Reestenosis Coronaria/diagnóstico por imagen , Reestenosis Coronaria/epidemiología , Reestenosis Coronaria/etiología , Anciano , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/cirugía , Síndrome Coronario Agudo/terapia , Angioplastia Coronaria con Balón/métodos , Angioplastia Coronaria con Balón/instrumentación , Angiografía Coronaria/métodos , Estudios de Seguimiento , Materiales Biocompatibles Revestidos , Resultado del Tratamiento , Intervención Coronaria Percutánea/métodos , Intervención Coronaria Percutánea/instrumentaciónRESUMEN
OBJECTIVE: Nowadays, the frequency of complications is also increasing following the increasing frequency of coronary angiography and percutaneous coronary intervention. Contrast-induced nephropathy is one of the most common of these complications. This study aimed to investigate the relationship between the Osaka prognostic score, which has previously been shown to have prognostic importance in gastrointestinal malignancies, and the development of contrast-induced nephropathy. METHODS: The study retrospectively examined the data of 1,498 patients who underwent coronary angiography and percutaneous coronary intervention due to acute coronary syndrome between 2018 and 2023. Demographic characteristics and laboratory findings were retrospectively collected from patients' charts and electronic medical records. RESULTS: Osaka prognostic score (0.84±0.25 vs. 2.2±0.32, p<0.001) was higher in patients who developed contrast-induced nephropathy. Also, Osaka prognostic score [OR 2.161 95%CI (1.101-4.241), p<0.001] was found to be an independent risk factor along with age, diabetes mellitus, systolic pulmonary artery pressure, hemoglobin, hemoglobin, C-reactive protein, albumin, N-terminal brain natriuretic peptide, and systemic immune-inflammation index. The receiver operating characteristic curve showed that the optimal cutoff value of Osaka prognostic score to predict the development of contrast-induced nephropathy was 1.5, with a sensitivity of 83.4 and a specificity of 65.9% [area under the curve: 0.874 (95%CI: 0.850-0.897, p≤0.001)]. CONCLUSION: Osaka prognostic score may be an easily calculable, user-friendly, and useful parameter to predict the development of contrast-induced nephropathy in patients undergoing percutaneous coronary intervention after acute coronary syndromes.
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Medios de Contraste , Angiografía Coronaria , Humanos , Medios de Contraste/efectos adversos , Femenino , Masculino , Estudios Retrospectivos , Persona de Mediana Edad , Anciano , Factores de Riesgo , Pronóstico , Angiografía Coronaria/efectos adversos , Intervención Coronaria Percutánea/efectos adversos , Síndrome Coronario Agudo/inducido químicamente , Síndrome Coronario Agudo/diagnóstico por imagen , Curva ROC , Medición de Riesgo , Lesión Renal Aguda/inducido químicamente , Enfermedades Renales/inducido químicamente , Valor Predictivo de las PruebasRESUMEN
BACKGROUND: Combining morphological and physiological evaluations might improve the risk stratification of patients who undergo percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) culprit lesions. AIMS: We aimed to investigate the clinical utility of morphofunctional evaluation after PCI for identifying ACS patients with increased risk of subsequent clinical events. METHODS: We retrospectively studied 298 consecutive ACS patients who had undergone optical coherence tomography (OCT)-guided PCI. We performed OCT-based morphological analysis and quantitative flow ratio (QFR)-based physiological assessment immediately after PCI. The non-culprit segment (NCS) was defined as the most stenotic untreated segment in the culprit vessel. The primary outcome was target vessel failure (TVF), a composite of cardiac death, target vessel-related myocardial infarction, and ischaemia-driven target vessel revascularisation. RESULTS: During a median follow-up period of 990 days, 42 patients experienced TVF. Cox regression analysis revealed that the presence of thin-cap fibroatheroma (TCFA) in the NCS and a low post-PCI QFR, or the presence of TCFA in the NCS and a high ΔQFR in the NCS (QFRNCS), were independently associated with TVF. The subgroup with TCFA in the NCS and a low post-PCI QFR had a significantly higher incidence of TVF (75%) than the other subgroups, and those with TCFA in the NCS and a high ΔQFRNCS had a significantly higher incidence of TVF (86%) than the other subgroups. The integration of TCFA in NCS, post-PCI QFR, and ΔQFRNCS with traditional risk factors significantly enhanced the identification of subsequent TVF cases. CONCLUSIONS: Combining post-PCI OCT and QFR evaluation may enhance risk stratification for ACS patients after successful PCI, particularly in predicting subsequent TVF.
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Síndrome Coronario Agudo , Intervención Coronaria Percutánea , Tomografía de Coherencia Óptica , Humanos , Tomografía de Coherencia Óptica/métodos , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/fisiopatología , Síndrome Coronario Agudo/terapia , Masculino , Femenino , Persona de Mediana Edad , Anciano , Estudios Retrospectivos , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Resultado del Tratamiento , Medición de Riesgo , Factores de Riesgo , Angiografía CoronariaRESUMEN
Acute coronary syndromes (ACS) are one of the leading causes of mortality worldwide, with atherosclerotic plaque rupture and subsequent thrombus formation as the main underlying substrate. Thrombus burden evaluation is important for tailoring treatment therapy and predicting prognosis. Coronary optical coherence tomography (OCT) enables in-vivo visualization of thrombus that cannot otherwise be achieved by other image modalities. However, automatic quantification of thrombus on OCT has not been implemented. The main challenges are due to the variation in location, size and irregularities of thrombus in addition to the small data set. In this paper, we propose a novel dual-coordinate cross-attention transformer network, termed DCCAT, to overcome the above challenges and achieve the first automatic segmentation of thrombus on OCT. Imaging features from both Cartesian and polar coordinates are encoded and fused based on long-range correspondence via multi-head cross-attention mechanism. The dual-coordinate cross-attention block is hierarchically stacked amid convolutional layers at multiple levels, allowing comprehensive feature enhancement. The model was developed based on 5,649 OCT frames from 339 patients and tested using independent external OCT data from 548 frames of 52 patients. DCCAT achieved Dice similarity score (DSC) of 0.706 in segmenting thrombus, which is significantly higher than the CNN-based (0.656) and Transformer-based (0.584) models. We prove that the additional input of polar image not only leverages discriminative features from another coordinate but also improves model robustness for geometrical transformation.Experiment results show that DCCAT achieves competitive performance with only 10% of the total data, highlighting its data efficiency. The proposed dual-coordinate cross-attention design can be easily integrated into other developed Transformer models to boost performance.
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Tomografía de Coherencia Óptica , Tomografía de Coherencia Óptica/métodos , Humanos , Algoritmos , Trombosis Coronaria/diagnóstico por imagen , Síndrome Coronario Agudo/diagnóstico por imagen , Interpretación de Imagen Asistida por Computador/métodosRESUMEN
BACKGROUND: Pulmonary embolisms (PEs) exhibit clinical features similar to those of acute coronary syndrome (ACS), including electrocardiographic abnormalities and elevated troponin levels, which frequently lead to misdiagnoses in emergency situations. CASE PRESENTATION: Here, we report a case of PE coinciding with chronic coronary syndrome in which the patient's condition was obscured by symptoms mimicking ACS. A 68-year-old female with syncope presented to the hospital. Upon admission, she was found to have elevated troponin levels and an electrocardiogram showing ST-segment changes across multiple leads, which initially led to a diagnosis of ACS. Emergency coronary arteriography revealed occlusion of the posterior branches of the left ventricle of the right coronary artery, but based on the complexity of the intervention, the occlusion was considered chronic rather than acute. On the 3rd day after admission, the patient experienced recurrent chest tightness and shortness of breath, which was confirmed as acute PE by emergency computed tomography pulmonary angiography. Following standardized anticoagulation treatment, the patient improved and was subsequently discharged. CONCLUSIONS: This case report highlights the importance of recognizing the nonspecific features of PE. Clinicians should be vigilant when identifying other clinical features that are difficult to explain accompanying the expected disease, and it is necessary to carefully identify the causes to prevent missed diagnoses or misdiagnoses.
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Síndrome Coronario Agudo , Anticoagulantes , Angiografía por Tomografía Computarizada , Electrocardiografía , Valor Predictivo de las Pruebas , Embolia Pulmonar , Humanos , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/diagnóstico por imagen , Femenino , Anciano , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/complicaciones , Síndrome Coronario Agudo/diagnóstico por imagen , Diagnóstico Diferencial , Anticoagulantes/uso terapéutico , Angiografía Coronaria , Enfermedad Crónica , Resultado del Tratamiento , Errores Diagnósticos , Biomarcadores/sangreRESUMEN
Patients with acute coronary syndrome (ACS), frequently caused by plaque rupture (PR), often have vulnerable plaques in residual lesions as well as in culprit lesions. However, whether this occurs in patients with plaque erosion (PE) as well is unknown. We retrospectively analyzed the data of 88 patients with ACS who underwent both optimal coherence tomography (OCT) and intravascular ultrasound (IVUS). Based on plaque morphology of the culprit lesions identified using OCT, patients were classified into PE (n=23) and PR (n=35) groups. The tissue characteristics of residual lesions evaluated using integrated backscatter IVUS were compared between both groups after percutaneous coronary intervention. The PE group had a significantly lower percent lipid volume and a higher percent fibrous volume than the PR group (35.0±17.8% vs 49.2±13.4%, p<0.001; 63.2±17.1% vs 50.3±13.1%, p=0.002, respectively). Receiver operating characteristic curve analysis revealed that percent lipid volume in the residual lesions was a significant discriminant factor in estimating the plaque morphology of the culprit lesion (optimal cut-off value, <43.5%; sensitivity and specificity values were 73.9% and 68.6%, respectively). In conclusion, patients with PE had a significantly lower percent lipid volume and a significantly higher percent fibrous volume in the residual lesions than those with PR, suggesting that the nature of coronary plaques in patients with PE is different from that of those with PR.
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Síndrome Coronario Agudo , Placa Aterosclerótica , Tomografía de Coherencia Óptica , Ultrasonografía Intervencional , Humanos , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/patología , Estudios Retrospectivos , Masculino , Femenino , Placa Aterosclerótica/diagnóstico por imagen , Placa Aterosclerótica/patología , Persona de Mediana Edad , Anciano , Ultrasonografía Intervencional/métodos , Tomografía de Coherencia Óptica/métodos , Intervención Coronaria Percutánea , Rotura Espontánea , Curva ROC , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/patologíaRESUMEN
BACKGROUND: At present, the diagnosis of acute coronary syndrome (ACS) can be made by emergency physicians using the usual complementary tests, since the current troponin and electrocardiogram (ECG) protocols have been extensively tested for their safety. However, the detection of coronary calcifications on CT associated with coronary obstruction may be of interest for the diagnostic strategy in the emergency department (ED). The aim of this study was to evaluate a strategy combining a non-ischemic ECG with an initial normal troponin assay and the diagnostic accuracy of chest CT in detecting coronary calcifications to rule out the presence of an acute coronary event in patients presenting with chest pain in the ED. METHODS: This was a retrospective, single-center study carried out in an ED in France and included all patients over 18 years of age presenting with chest pain between 1 June 2021 and 31 December 2021 with a non-ischemic ECG and a negative first troponin assay. The primary endpoint was the diagnostic performance of the combing strategy in ruling out ACS. The secondary endpoints were the sensitivity and specificity of calcifications in acute coronary syndrome, comparison with the diagnostic performance of a second troponin assay and the rate of reconsultation, rehospitalisation and investigations within 2 months of the ED. RESULTS: Of the 280 patients included, 141 didn't have calcifications. A total of 14 events were found with a negative predictive value for the combining strategy of 99.8% [95%CI: 98.2 - 100]. Sensitivity and specificity were 98.4% [95%CI: 83.8 - 100] and 53% [95%CI: 47 - 58.9], respectively. Among patients with no calcification, 8.2% were admitted to hospital and none suffered an acute coronary event. A total of 36 patients (12.8%) consulted a doctor within 2 months, with 23 investigations, all of which were negative in the non-calcification group. CONCLUSIONS: A strategy combining the detection of coronary calcifications on chest CT in patients with a non-ischemic ECG and a single troponin assay is effective to rule out ACS in the ED, and may perform better then ECG and troponin alone.
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Síndrome Coronario Agudo , Electrocardiografía , Servicio de Urgencia en Hospital , Tomografía Computarizada por Rayos X , Humanos , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/diagnóstico , Femenino , Masculino , Estudios Retrospectivos , Persona de Mediana Edad , Anciano , Troponina/sangre , Dolor en el Pecho/etiología , Dolor en el Pecho/diagnóstico por imagen , Francia , Sensibilidad y Especificidad , Calcinosis/diagnóstico por imagen , Calcificación Vascular/diagnóstico por imagenRESUMEN
OBJECTIVE: The study aimed to evaluate the effect of the SYNTAX score (SS) calculated before percutaneous intervention on survival in a group of young patients with acute coronary syndrome (ACS). PATIENTS AND METHODS: Our study is a retrospective study. Patients between the ages of 18 and 45 who applied to Private Yalova Atakent Hospital Cardiology Clinic with ACS and underwent percutaneous coronary intervention between 01.01.2017 and 01.12.2023 were included in the study. Patients aged 45 and under who presented with acute syndrome and underwent coronary angiography were evaluated. Patients' history of major cardiac adverse events (MACE) was evaluated. Demographic characteristics, laboratory findings, echocardiographic parameters, and SS of the patients were recorded. SS was calculated from the coronary angiography images of the patients. RESULTS: 140 patients were included in the study. 70.0% (n=98) of the cases were diagnosed with ST-elevation myocardial infarction (STE-MI), 28.6% (n=40) with non-ST-elevation myocardial infarction (NSTE-MI)-unstable angina pectoris (USAP), and 1.4% with cardiac arrest (n=2). 28.6% (n=40) of the patients had MACE. There was a statistically significant correlation between SS and MACE (r=0.525 p=0.001). An SS value of 23.15 had 77.5% sensitivity and 60.8% specificity in predicting MACE. There was a statistically significant negative correlation between SS and ejection fraction (EF) (r=-0.584, p=0.001). EF<40.5 predicted mortality with 77.7% sensitivity and 69.4% specificity (AUC 0.710, p=0.01, 95% CI 0.615-0.825). CONCLUSIONS: SYNTAX Score and EF have predictive value in predicting MACE and mortality in young ACS patients. Different scoring systems are needed to predict MACE and mortality after ACS in young patients.
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Síndrome Coronario Agudo , Angiografía Coronaria , Intervención Coronaria Percutánea , Humanos , Síndrome Coronario Agudo/mortalidad , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/terapia , Masculino , Femenino , Estudios Retrospectivos , Adulto , Persona de Mediana Edad , Adolescente , Adulto JovenAsunto(s)
Síndrome Coronario Agudo , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Valor Predictivo de las Pruebas , Humanos , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/terapia , Pronóstico , Factores de Riesgo , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Medición de Riesgo , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: In 5%-25% of non-ST-elevation acute coronary syndrome (NSTE-ACS) patients, coronary angiography reveals no obstructive coronary arteries (MINOCA). Coronary microvascular disease (CMD) is a potential causal pathophysiological mechanism in these patients and can be diagnosed by continuous thermodilution assessment. Recently, the microvascular resistance reserve (MRR) has been introduced as a novel index to assess the vasodilatory capacity of the microcirculation. However, continuous thermodilution and MRR have never been investigated in the acute setting in MINOCA patients and invasive assessment of the microcirculation in these patients are currently lacking. AIMS: The objectives of the study were to investigate the incidence of CMD (MRR ≤ 2.7) in patients with MINOCA and to evaluate the feasibility and safety of continuous thermodilution-based assessment during index coronary angiography in the acute setting. METHODS: This study was a prospective, observational, pilot study investigating coronary physiology in the acute setting in MINOCA patients. Patients admitted with a diagnosis of NSTE-ACS were eligible for inclusion. RESULTS: In total, 19 MINOCA patients were included in this analysis; the mean age was 70 ± 9 years, and 79% were females. CMD was present in 6 patients (32%). Qrest was significantly higher in the MRR ≤ 2.7 group compared to the MRR > 2.7 group (0.076 [0.057-0.100] vs. 0.049 [0.044-0.071] L/min, p = 0.03). Rµ,rest was significantly lower in the MRR ≤ 2.7 group compared to the MRR > 2.7 group (1083 [710-1510] vs. 1563 [1298-1970] WU, p = 0.04). No periprocedural complications or hemodynamic instability have occurred during continuous thermodilution assessment during the index coronary angiography. CONCLUSION: In patients admitted for MINOCA undergoing immediate coronary angiography, continuous thermodilution assessment and MRR are feasible and safe in the acute setting, and evidence of functional CMD could be observed in one-third of the MINOCA patients.
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Síndrome Coronario Agudo , Angiografía Coronaria , Circulación Coronaria , Estudios de Factibilidad , Microcirculación , Valor Predictivo de las Pruebas , Termodilución , Resistencia Vascular , Humanos , Proyectos Piloto , Femenino , Masculino , Anciano , Estudios Prospectivos , Persona de Mediana Edad , Síndrome Coronario Agudo/fisiopatología , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/terapia , Vasos Coronarios/fisiopatología , Vasos Coronarios/diagnóstico por imagen , Cateterismo Cardíaco , Infarto del Miocardio sin Elevación del ST/fisiopatología , Infarto del Miocardio sin Elevación del ST/diagnóstico por imagen , Infarto del Miocardio sin Elevación del ST/terapia , Vasodilatación , Anciano de 80 o más AñosRESUMEN
Point-of-care ultrasound (POCUS) is an important tool for clinical diagnosis and decision-making in critical and non-critical scenarios. Dyspnea, chest pain, and shock are conditions susceptible to evaluation with ultrasound considering diagnostic accuracy and clinical impact already proven. There is scarce evidence in diagnosis agreement using ultrasound as an extension of physical examination. We aimed to evaluate ED patients in whom POCUS was performed, to analyze agreement between clinical initial diagnosis using ultrasound images and final diagnosis. Furthermore, we analyze failed diagnosis, inconclusive POCUS exams, and discuss details. A cross-sectional analytical study was conducted on adults who visited the emergency department with any of these three chief complaints: dyspnea, chest pain, and shock. All were evaluated with ultrasound at admission. Agreement between initial diagnosis using POCUS and final definite diagnosis was calculated. Failed diagnosis and inconclusive exams were analyzed. A total of 209 patients were analyzed. Populations: mostly males, mean age 64 years old, hypertensive. Agreement on patients with dyspnea and suspicion of acute decompensated heart failure was 0.98; agreement on chest pain suspicion of non-ST acute coronary syndrome was 0.96; agreement on type of shock was 0.90. Among the population, 12 patients had an inconclusive POCUS exam, and 16 patients had a failed diagnosis. The use of POCUS in the emergency department shows almost perfect agreement when compared with the final diagnosis in individuals experiencing acutely decompensated heart failure, acute coronary syndrome, and shock. Prospective studies are needed to evaluate the impact of this tool on mortality and prognosis when there are diagnostic errors.
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Síndrome Coronario Agudo , Insuficiencia Cardíaca , Sistemas de Atención de Punto , Choque , Ultrasonografía , Humanos , Masculino , Femenino , Persona de Mediana Edad , Estudios Transversales , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/diagnóstico , Sistemas de Atención de Punto/normas , Sistemas de Atención de Punto/estadística & datos numéricos , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/complicaciones , Ultrasonografía/métodos , Ultrasonografía/estadística & datos numéricos , Anciano , Choque/diagnóstico por imagen , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Disnea/etiología , Dolor en el Pecho/etiologíaRESUMEN
BACKGROUND: We aimed to clarify the predictive value of cerebral small-vessel disease and intracranial large artery disease (LAD) observed in magnetic resonance imaging of the brain and magnetic resonance angiography on future vascular events and cognitive impairment. METHODS AND RESULTS: Data were derived from a Japanese cohort with evidence of cerebral vessel disease on magnetic resonance imaging. This study included 862 participants who underwent magnetic resonance angiography after excluding patients with a modified Rankin Scale score >1 and Mini-Mental State Examination score <24. We evaluated small-vessel disease such as white matter hyperintensities and lacunes in magnetic resonance imaging and LAD with magnetic resonance angiography. Outcomes were incident stroke, dementia, acute coronary syndrome, and all-cause death. Over a median follow-up period of 4.5 years, 54 incident stroke, 39 cases of dementia, and 27 cases of acute coronary syndrome were documented. Both small-vessel disease (white matter hyperintensities and lacunes) and LAD were associated with stroke; however, only white matter hyperintensities were related to dementia. In contrast, only LAD was associated with acute coronary syndrome. Among the 357 patients with no prior history of stroke, coronary or peripheral artery disease, or atrial fibrillation, white matter hyperintensities emerged as the sole predictor of future stroke and dementia, while LAD was the sole predictor of acute coronary syndrome. CONCLUSIONS: Among cerebral vessels, small-vessel disease could underlie the cognitive impairment while LAD was associated with coronary artery disease as atherosclerotic vessel disease.
Asunto(s)
Síndrome Coronario Agudo , Enfermedades de los Pequeños Vasos Cerebrales , Demencia , Valor Predictivo de las Pruebas , Humanos , Masculino , Femenino , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/epidemiología , Síndrome Coronario Agudo/diagnóstico , Estudios Prospectivos , Anciano , Demencia/epidemiología , Demencia/diagnóstico por imagen , Persona de Mediana Edad , Enfermedades de los Pequeños Vasos Cerebrales/diagnóstico por imagen , Enfermedades de los Pequeños Vasos Cerebrales/epidemiología , Japón/epidemiología , Angiografía por Resonancia Magnética , Factores de Riesgo , Medición de Riesgo , Imagen por Resonancia Magnética , Incidencia , Pronóstico , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/etiología , Encéfalo/diagnóstico por imagen , Encéfalo/patologíaRESUMEN
BACKGROUND: The HEART score, the T-MACS model and the GRACE score support early decision-making for acute chest pain, which could be complemented by CT coronary angiography (CTCA). However, their performance has not been directly compared. METHODS: In this secondary analysis of a multicentre randomised controlled trial of early CTCA in intermediate-risk patients with suspected acute coronary syndrome, C-statistics and performance metrics (using the predefined cut-offs) of clinical decision aids and CTCA, alone and then in combination, for the index hospital diagnosis of acute coronary syndrome and for 30-day coronary revascularisation were assessed in those who underwent CTCA and had complete data. RESULTS: Among 699 patients, 358 (51%) had an index hospital diagnosis of acute coronary syndrome, for which the C-statistic was higher for CTCA (0.80), followed by the T-MACS model (0.78), the HEART score (0.74) and the GRACE score (0.60). The negative predictive value was higher for the absence of coronary artery disease on CTCA (0.90) or a T-MACS estimate of <0.05 (0.83) than a HEART score of <4 (0.81) and a GRACE score of <109 (0.55). For 30-day coronary revascularisation, CTCA had the greatest C-statistic (0.80) with a negative predictive value of 0.96 and 0.92 in the absence of coronary artery disease and obstructive coronary artery disease, respectively. The combination of the T-MACS estimates and the CTCA findings was most discriminative for the index hospital diagnosis of acute coronary syndrome (C-statistic, 0.88) and predictive of 30-day coronary revascularisation (C-statistic, 0.85). No patients with a T-MACS estimate of <0.05 and normal coronary arteries had acute coronary syndrome during index hospitalisation or underwent coronary revascularisation within 30 days. CONCLUSIONS: In intermediate-risk patients with suspected acute coronary syndrome, the T-MACS model combined with CTCA improved discrimination of the index hospital diagnosis of acute coronary syndrome and prediction of 30-day coronary revascularisation. TRIAL REGISTRATION NUMBER: NCT02284191.
Asunto(s)
Síndrome Coronario Agudo , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Técnicas de Apoyo para la Decisión , Humanos , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/diagnóstico , Masculino , Femenino , Persona de Mediana Edad , Angiografía Coronaria/métodos , Angiografía Coronaria/estadística & datos numéricos , Angiografía por Tomografía Computarizada/métodos , Anciano , Valor Predictivo de las Pruebas , Medición de Riesgo/métodos , Tomografía Computarizada por Rayos X/métodosRESUMEN
BACKGROUND AND OBJECTIVE: Coronary plaque rupture is a precipitating event responsible for two thirds of myocardial infarctions. Currently, the risk of plaque rupture is computed based on demographic, clinical, and image-based adverse features. However, using these features the absolute event rate per single higher-risk lesion remains low. This work studies the power of a novel framework based on biomechanical markers accounting for material uncertainty to stratify vulnerable and non-vulnerable coronary plaques. METHODS: Virtual histology intravascular ultrasounds from 55 patients, 29 affected by acute coronary syndrome and 26 affected by stable angina pectoris, were included in this study. Two-dimensional vessel cross-sections for finite element modeling (10 sections per plaque) incorporating plaque structure (medial tissue, loose matrix, lipid core and calcification) were reconstructed. A Montecarlo finite element analysis was performed on each section to account for material variability on three biomechanical markers: peak plaque structural stress at diastolic and systolic pressure, and peak plaque stress difference between systolic and diastolic pressures, together with the luminal pressure. Machine learning decision tree classifiers were trained on 75% of the dataset and tested on the remaining 25% with a combination of feature selection techniques. Performance against classification trees based on geometric markers (i.e., luminal, external elastic membrane and plaque areas) was also performed. RESULTS: Our results indicate that the plaque structural stress outperforms the classification capacity of the combined geometric markers only (0.82 vs 0.51 area under curve) when accounting for uncertainty in material parameters. Furthermore, the results suggest that the combination of the peak plaque structural stress at diastolic and systolic pressures with the maximum plaque structural stress difference between systolic and diastolic pressures together with the systolic pressure and the diastolic to systolic pressure gradient is a robust classifier for coronary plaques when the intrinsic variability in material parameters is considered (area under curve equal to [0.91-0.93]). CONCLUSION: In summary, our results emphasize that peak plaque structural stress in combination with the patient's luminal pressure is a potential classifier of plaque vulnerability as it independently considers stress in all directions and incorporates total geometric and compositional features of atherosclerotic plaques.
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Análisis de Elementos Finitos , Placa Aterosclerótica , Humanos , Placa Aterosclerótica/diagnóstico por imagen , Placa Aterosclerótica/fisiopatología , Masculino , Femenino , Fenómenos Biomecánicos , Aprendizaje Automático , Persona de Mediana Edad , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/fisiopatología , Anciano , Estrés Mecánico , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/fisiopatología , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Ultrasonografía IntervencionalRESUMEN
We report three cases of coronary artery aneurysm (CAA) in adults who presented with acute coronary syndrome. Two of these patients did not have traditional coronary artery disease risk factors. Management of CAA poses a significant challenge to interventionalists. We discuss the etiologic mechanisms, risk factors, pathophysiology, and diagnosis using angiography, intravascular ultrasound, and coronary computed tomography. We also highlight management options, including medical therapy and catheter-based interventions such as stenting, coil embolization, stent-assisted coil embolization, and surgical exclusion.