RESUMO
BACKGROUND: The prognosis of myocardial ischaemia with no obstructive coronary artery disease (INOCA) and its underlying vasomotor disorders, vasospastic angina (VSA) and microvascular angina (MVA), is not well defined. The aim of this study was to perform a systematic review and meta-analysis of studies evaluating the long-term prognosis of patients with INOCA. METHODS: We included studies evaluating the prognosis of patients with INOCA published between January 1984 and August 2023 in Medline, Embase, Web of Science and Cochrane databases. Studies were selected if they included patients who fulfilled the Coronary Vasomotor Disorders International Study Group (COVADIS) criteria for either possible or definitive VSA or MVA. The primary outcomes were composite of all-cause death and myocardial infarction (MI), and major adverse cardiovascular event (MACE) at annual intervals up to 5-year follow-up. The incidence of primary outcomes for INOCA, each INOCA endotype and by method used to determine the diagnosis was calculated using the random effects model. RESULTS: Fifty-four studies (17 302 patients) meeting the eligibility criteria were selected. The rate of all-cause death and MI with VSA was 0.7 (95% CI 0.4 to 1.0)/100 patient-years and with MVA was 1.1 (95% CI 0.7 to 1.5)/100 patient-years (p>0.05). The rate of MACE with VSA was 1.1 (95% CI 0.5 to 1.9)/100 patient-years and with MVA was 2.5 (95% CI 1.6 to 3.6)/100 patient-years (p=0.025). Patients with reduced coronary flow reserve (CFR) had higher all-cause death and MI rates than patients whose diagnosis of MVA was established based on an abnormal exercise or imaging stress test (4.7 (95% CI 2.0 to 8.4) vs 0.5 (95% CI 0.1 to 1.1) vs 1.1 (95% CI 0.5 to 2.0)/100 patient-years, p=0.001). CONCLUSIONS: Overall, patients with INOCA have a low rate of MACEs, but patients with MVA, especially those with reduced CFR, have a significantly higher rate of MACE than other subgroups, although there is high heterogeneity among the included studies. PROSPERO REGISTRATION NUMBER: CRD42021275070.
Assuntos
Isquemia Miocárdica , Humanos , Prognóstico , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/epidemiologia , Isquemia Miocárdica/fisiopatologia , Fatores de Tempo , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Saúde Global , Fatores de Risco , Medição de Risco/métodos , Vasoespasmo Coronário/diagnóstico , Vasoespasmo Coronário/fisiopatologia , Angina Microvascular/diagnóstico , Angina Microvascular/fisiopatologia , Angina Microvascular/mortalidade , Causas de Morte/tendênciasRESUMO
Accurate prediction of coronary artery disease (CAD) is crucial for enabling early clinical diagnosis and tailoring personalized treatment options. This study attempts to construct a machine learning (ML) model for predicting CAD risk and further elucidate the complex nonlinear interactions between the disease and its risk factors. Employing the Z-Alizadeh Sani dataset, which includes records of 303 patients, univariate analysis and the Boruta algorithm were applied for feature selection, and nine different ML techniques were subsequently deployed to produce predictive models. To elucidate the intricate pathogenesis of CAD, this study harnessed the analytical capabilities of Shapley values, alongside the use of generalized additive models for curve fitting, to probe into the nonlinear interactions between the disease and its associated risk factors. Furthermore, we implemented a piecewise linear regression model to precisely pinpoint inflection points within these complex nonlinear dynamics. The findings of this investigation reveal that logistic regression (LR) stands out as the preeminent predictive model, demonstrating remarkable efficacy, it achieved an Area Under the Receiver Operating Characteristic curve (AUROC) of 0.981 (95% CI: 0.952-1), and an Area Under the Precision-Recall Curve (AUPRC) of 0.993. The utilization of the 14 most pivotal features in constructing a dynamic nomogram. Analysis of the Shapley smoothing curves uncovered distinctive "S"-shaped and "C"-shaped relationships linking age and triglycerides to CAD, respectively. In summary, machine learning models could provide valuable insights for the early diagnosis of CAD. The SHAP method may provide a personalized risk assessment of the relationship between CAD and its risk factors.
Assuntos
Doença da Artéria Coronariana , Aprendizado de Máquina , Humanos , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/epidemiologia , Feminino , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Curva ROC , Idoso , Modelos Logísticos , Algoritmos , Nomogramas , Medição de Risco/métodosRESUMO
Despite the well-established significance of the CAC score as a cardiovascular risk marker, the timing of using CAC score in routine clinical practice remains unclear. We aim to develop a prediction model for patients visiting outpatient cardiology units, which can recommend whether CAC score screening is necessary. A prediction model using retrospective cross-sectional design was conducted. Patients who underwent CAC score screening were included. Eight candidate predictors were preselected, including age, gender, DM or primary hypertension, angina chest pain, LDL-C (≥130 mg/dl), presence of low HDL-C, triglyceride (≥150 mg/dl), and eGFR. The outcome of interest was the level of CAC score (CAC score 0, CAC score 1-99, CAC score ≥100). The model was developed using ordinal logistic regression, and model performance was evaluated in terms of discriminative ability and calibration. A total of 360 patients were recruited for analysis, comprising 136 with CAC score 0, 133 with CAC score 1-99, and 111 with CAC score ≥100. The final predictors identified were age, male gender, presence of hypertension or DM, and low HDL-C. The model demonstrated excellent discriminative ability (Ordinal C-statistics of 0.81) with visually good agreement on calibration plots. The implementation of this model (CAC-prob) has the potential to enhance precision in recommending CAC screening. However, external validation is necessary to assess its robustness in new patient cohorts.
Assuntos
Doença da Artéria Coronariana , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Estudos Retrospectivos , Doença da Artéria Coronariana/diagnóstico , Estudos Transversais , Pacientes Ambulatoriais , Programas de Rastreamento/métodos , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/metabolismo , Fatores de Risco , Cálcio/metabolismo , Cálcio/análise , Calcificação Vascular/diagnóstico , Calcificação Vascular/diagnóstico por imagemAssuntos
Doença da Artéria Coronariana , Revascularização Miocárdica , Humanos , Doença da Artéria Coronariana/cirurgia , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/terapia , Prognóstico , Revascularização Miocárdica/métodos , Doença Crônica , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/terapia , Isquemia Miocárdica/cirurgia , Valor Preditivo dos Testes , Angiografia CoronáriaRESUMO
BACKGROUND: Clopidogrel monotherapy improved clinical outcomes compared with aspirin monotherapy during a chronic maintenance period in patients who underwent coronary stenting in the HOST-EXAM (Harmonizing Optimal Strategy for Treatment of Coronary Artery Stenosis-Extended Antiplatelet Monotherapy) trial. However, it is uncertain whether the beneficial effect of clopidogrel over aspirin is different according to the renal function. METHODS AND RESULTS: We conducted a post hoc analysis of the HOST-EXAM trial. Chronic kidney disease (CKD) was defined as baseline estimated glomerular filtration rate <60 mL/min per 1.73 m2. The primary end point was a composite of all-cause death, nonfatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and Bleeding Academic Research Consortium bleeding type ≥3, during the 2-year follow up. Among the 5438 patients enrolled in the HOST-EXAM trial, 4844 patients (mean age, 63.3±10.6 years; 74.9% men) with a baseline creatinine value were analyzed in this study. A total of 508 (10.5%) patients had CKD, who were at higher risk of the primary end point compared with those without CKD (hazard ratio [HR], 2.01 [95% CI, 1.51-2.67]). Clopidogrel monotherapy was associated with a lower rate of the primary end point in both patients with CKD (HR, 0.74 [95% CI, 0.44-1.25]) and patients without CKD (HR, 0.71 [95% CI, 0.56-0.91]). No significant interaction was observed between the treatment effect and CKD status (P for interaction=0.889). CONCLUSIONS: During the chronic maintenance period after coronary stenting, the risk of thrombotic and bleeding events was significantly higher in patients with CKD compared with those without CKD. There was no statistical difference in the treatment effect of clopidogrel monotherapy in those with versus without CKD.
Assuntos
Aspirina , Clopidogrel , Intervenção Coronária Percutânea , Inibidores da Agregação Plaquetária , Insuficiência Renal Crônica , Humanos , Clopidogrel/uso terapêutico , Clopidogrel/efeitos adversos , Clopidogrel/administração & dosagem , Masculino , Feminino , Inibidores da Agregação Plaquetária/efeitos adversos , Inibidores da Agregação Plaquetária/uso terapêutico , Inibidores da Agregação Plaquetária/administração & dosagem , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/fisiopatologia , Insuficiência Renal Crônica/terapia , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Aspirina/administração & dosagem , Aspirina/uso terapêutico , Aspirina/efeitos adversos , Idoso , Hemorragia/induzido quimicamente , Resultado do Tratamento , Taxa de Filtração Glomerular , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/terapia , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/mortalidade , Stents , Fatores de TempoRESUMO
BACKGROUND: Patients with osteoporosis demonstrate increased vascular calcification but the effect of osteoporosis treatments on vascular calcification remains unclear. The present study aimed to examine whether coronary or aortic calcification are influenced by denosumab and alendronic acid treatment. METHODS AND RESULTS: In a double-blind randomized controlled SALTIRE2 (Study Investigating the Effect of Drugs Used to Treat Osteoporosis on the Progression of Calcific Aortic Stenosis) trial, patients with aortic stenosis were randomized 2:1:2:1 to denosumab, placebo injection, alendronic acid, or placebo capsule. Participants underwent serial imaging with computed tomography and 18F-sodium fluoride positron emission tomography for the assessment of vascular calcium burden and calcification activity, respectively. We report the prespecified secondary analyses of 24-month change in coronary calcium score, and 12-month changes in thoracic aorta calcium score, coronary and aortic 18F-sodium fluoride activity. One hundred fifty patients with aortic stenosis (72±8 years; 21% female) were randomized to denosumab (n=49), alendronic acid (n=51), and placebo (injection n=25, capsule n=25). There were no differences in change in coronary calcium scores between placebo (16 [-64 to 148] Agatston units) and either denosumab (94 [0-212] Agatston units, P=0.24) or alendronic acid (34 [-62 to 134], P=0.99). There were no differences in change in thoracic aorta calcium scores between placebo (132 [22-512] Agatston units) and either denosumab (118 [11-340], P=0.75) or alendronic acid (116 [26-498] Agatston units, P=0.62). There were no differences in changes in coronary or aortic 18F-sodium fluoride activity between treatment groups. CONCLUSIONS: Neither alendronic acid nor denosumab are associated with changes in the activity or progression of coronary or aortic calcification. Osteoporosis treatments do not appear to have major impact on vascular calcification of atherosclerosis. REGISTRATION: https://www.clinicaltrials.gov; Unique identifier: NCT02132026.
Assuntos
Alendronato , Conservadores da Densidade Óssea , Denosumab , Calcificação Vascular , Humanos , Feminino , Masculino , Denosumab/uso terapêutico , Idoso , Método Duplo-Cego , Calcificação Vascular/diagnóstico por imagem , Alendronato/uso terapêutico , Conservadores da Densidade Óssea/uso terapêutico , Resultado do Tratamento , Estenose da Valva Aórtica/tratamento farmacológico , Estenose da Valva Aórtica/diagnóstico por imagem , Osteoporose/tratamento farmacológico , Osteoporose/diagnóstico por imagem , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Doença da Artéria Coronariana/tratamento farmacológico , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/diagnóstico , Tomografia por Emissão de Pósitrons , Fatores de TempoRESUMO
Registration URL: https://clinicaltrials.gov. Unique identifier: NCT02594111.
Assuntos
Biomarcadores , Colchicina , Doença da Artéria Coronariana , Ativação de Neutrófilo , Intervenção Coronária Percutânea , Humanos , Colchicina/uso terapêutico , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/imunologia , Doença da Artéria Coronariana/diagnóstico , Masculino , Feminino , Ativação de Neutrófilo/efeitos dos fármacos , Biomarcadores/sangue , Pessoa de Meia-Idade , Idoso , Neutrófilos/imunologia , Adesão Celular/efeitos dos fármacosRESUMO
BACKGROUND: After coronary stent implantation, prolonged dual antiplatelet therapy (DAPT) increases bleeding risk, requiring personalization of DAPT duration. The aim of this study was to develop and validate a machine learning model to predict optimal DAPT duration after contemporary drug-eluting stent implantation in patients with coronary artery disease. METHODS AND RESULTS: The One-Month DAPT, RESET (Real Safety and Efficacy of 3-Month Dual Antiplatelet Therapy Following Endeavor Zotarolimus-Eluting Stent Implantation), and IVUS-XPL (Impact of Intravascular Ultrasound Guidance on Outcomes of Xience Prime Stents in Long Lesion) trials provided a derivation cohort (n=6568). Using the X-learner approach, an individualized DAPT score was developed to determine the therapeutic benefit of abbreviated (1-6 months) versus standard (12-month) DAPT using various predictors. The primary outcome was major bleeding; the secondary outcomes included 1-year major adverse cardiac and cerebrovascular events and 1-year net adverse clinical events. The risk reduction with abbreviated DAPT (3 months) in the individualized DAPT-determined higher predicted benefit group was validated in the TICO (Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus-Eluting Stent for Acute Coronary Syndrome) trial (n=3056), which enrolled patients with acute coronary syndrome treated with ticagrelor. The validation cohort comprised 1527 abbreviated and 1529 standard DAPT cases. Major bleeding occurred in 25 (1.7%) and 45 (3.0%) patients in the abbreviated and standard DAPT groups, respectively. The individualized DAPT score identified 2582 (84.5%) participants who would benefit from abbreviated DAPT, which was significantly associated with a lower major bleeding risk (absolute risk difference [ARD], 1.26 [95% CI, 0.15-2.36]) and net adverse clinical events (ARD, 1.59 [95% CI, 0.07-3.10]) but not major adverse cardiac and cerebrovascular events (ARD, 0.63 [95% CI, -0.34 to 1.61]), compared with standard DAPT in the higher predicted benefit group. Abbreviated DAPT had no significant difference in clinical outcomes of major bleeding (ARD, 1.49 [95% CI, -1.74 to 4.72]), net adverse clinical events (ARD, 2.57 [95% CI, -1.85 to 6.99]), or major adverse cardiac and cerebrovascular events (ARD, 1.54 [95% CI, -1.26 to 4.34]), compared with standard DAPT in the individualized DAPT-determined lower predicted benefit group. CONCLUSIONS: Machine learning using the X-learner approach identifies patients with acute coronary syndrome who may benefit from abbreviated DAPT after drug-eluting stent implantation, laying the groundwork for personalized antiplatelet therapy.
Assuntos
Doença da Artéria Coronariana , Stents Farmacológicos , Terapia Antiplaquetária Dupla , Hemorragia , Aprendizado de Máquina , Intervenção Coronária Percutânea , Inibidores da Agregação Plaquetária , Humanos , Feminino , Masculino , Terapia Antiplaquetária Dupla/métodos , Inibidores da Agregação Plaquetária/administração & dosagem , Inibidores da Agregação Plaquetária/efeitos adversos , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/instrumentação , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Idoso , Doença da Artéria Coronariana/terapia , Doença da Artéria Coronariana/diagnóstico , Hemorragia/induzido quimicamente , Fatores de Tempo , Resultado do Tratamento , Medição de Risco , Esquema de Medicação , Fatores de RiscoRESUMO
Purpose: People living with HIV are twice as likely to develop cardiovascular diseases (CVDs) and myocardial infarction related to atherosclerosis than the uninfected population. This study aimed to evaluate the prevalence of subclinical atherosclerosis in a young, mid-eastern European population of PLWH receiving ART for undetectable viremia. Patients and Methods: This was a single-centre study. We included 34 patients below 50 years old, treated in Szczecin, Poland, with confirmed HIV-1 infection, treated with antiretroviral therapy (ART), and undetectable viremia. All patients underwent coronary artery computed tomography (CACT), carotid artery intima-media thickness (IMT) evaluation, and echocardiography. Results: In the primary assessment, only two (5.8%) patients had an increased CVD risk calculated using the Framingham Risk Score (FRS), but we identified coronary or carotid plaques in 26.5% of the patients. Neither traditional risk factors nor those associated with HIV significantly influenced the presence of the plaque. IMT was significantly positively correlated with age and the FRS (R=0.38, p=0.04). Relative wall thickness assessed in echocardiography was higher in those with plaque (0.49 vs 0.44, p=0.04) and significantly correlated with IMT (R=0.38, p=0.04). Conclusion: In our population, more than a quarter of PLWH with undetectable viremia had subclinical atherosclerosis in either the coronary or carotid arteries. The FRS underpredicted atherosclerosis in this population. The role of RWT as a possible early marker of atherosclerosis needs further studies.
Assuntos
Fármacos Anti-HIV , Espessura Intima-Media Carotídea , Infecções por HIV , Fatores de Risco de Doenças Cardíacas , Humanos , Masculino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Infecções por HIV/diagnóstico , Infecções por HIV/complicações , Feminino , Pessoa de Meia-Idade , Adulto , Polônia/epidemiologia , Prevalência , Medição de Risco , Fármacos Anti-HIV/uso terapêutico , Fármacos Anti-HIV/efeitos adversos , Dados Preliminares , Viremia/epidemiologia , Viremia/tratamento farmacológico , Doenças das Artérias Carótidas/epidemiologia , Doenças das Artérias Carótidas/diagnóstico por imagem , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/diagnóstico , Resultado do Tratamento , Placa Aterosclerótica , Angiografia por Tomografia Computadorizada , Doenças Assintomáticas , Angiografia Coronária , Fatores Etários , Resposta Viral Sustentada , Carga Viral , Fatores de Risco , Estudos TransversaisRESUMO
AIMS: To assess the diagnostic accuracy of dobutamine stress echocardiography (DSE) in symptomatic patients with a low to intermediate pretest probability of obstructive coronary artery disease (CAD) and a positive coronary CT angiography (CCTA). METHODS: We prospectively enrolled 104 consecutive patients undergoing coronary angiography for symptoms of stable CAD and a CCTA indicative of obstructive CAD. The diagnostic performance of DSE was evaluated against two intracoronary pressure indices: (a) fractional flow reserve (FFR) with a cut-off of ≤0.80 and (b) instantaneous wave-free ratio (iFR) with a cut-off of ≤0.89, indicating haemodynamically significant stenoses. RESULTS: Of 102 patients, 46 (45%) had at least one significant lesion as defined by FFR, as did 37 (36%) as defined by iFR. DSE showed positive results in 33% (34/102) of cases. The discriminative power of DSE for detecting significant CAD was moderate, with areas under the curve of 0.63 (p=0.024) compared with FFR and 0.64 (p=0.025) compared with iFR. The accuracy, sensitivity and specificity of DSE were, respectively, 61%, 43%, and 75% against FFR, and 64%, 46% and 74% against iFR. The diagnostic accuracy of DSE did not differ significantly between FFR and iFR as a reference (p=0.549). CONCLUSION: In patients with positive CCTA, DSE has a moderate ability to identify haemodynamically significant CAD, with low sensitivity and moderate specificity. When assessed against FFR and iFR criteria, its additive diagnostic value is limited in patients with low to intermediate pretest probability of obstructive CAD. TRIAL REGISTRATION NUMBER: NCT03045601.
Assuntos
Angiografia por Tomografia Computadorizada , Angiografia Coronária , Doença da Artéria Coronariana , Ecocardiografia sob Estresse , Reserva Fracionada de Fluxo Miocárdico , Valor Preditivo dos Testes , Humanos , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Masculino , Feminino , Ecocardiografia sob Estresse/métodos , Ecocardiografia sob Estresse/normas , Estudos Prospectivos , Angiografia Coronária/métodos , Pessoa de Meia-Idade , Idoso , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/diagnóstico , Reprodutibilidade dos Testes , Angiografia por Tomografia Computadorizada/métodos , Angiografia por Tomografia Computadorizada/normas , Estenose Coronária/fisiopatologia , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/diagnóstico , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/fisiopatologia , Dobutamina/administração & dosagem , Padrões de ReferênciaRESUMO
BACKGROUND: This study aimed to evaluate six novel lymphocyte-based inflammatory markers (neutrophil-lymphocyte ratio, monocyte-lymphocyte ratio, platelet-lymphocyte ratio [PLR], systemic immune inflammation index [SII], systemic inflammatory response index, and systemic immune inflammation response index [SIIRI]) in patients with newly diagnosed coronary artery disease [CAD]. METHODS: A total of 959 patients newly diagnosed with CAD and underwent diagnostic coronary angiography were enrolled in this study and followed for major adverse cardiovascular events (MACEs), including cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke. The best cutoff value was used to compare the six indicators. Cox risk regression analysis evaluated the relationship between novel lymphocyte-based inflammatory markers and MACEs in newly diagnosed CAD patients. RESULTS: During a mean follow-up period of 33.3 ± 9.9 months, 229 (23.9%) MACEs were identified. Multivariate Cox regression analysis showed that only SIIRI (hazard ratio [HR]: 5.853; 95% confidence interval [CI]: 4.092-8.371; p < .001) and PLR (HR: 1.725; 95% CI: 1.214-2.452; p = .002) were independent predictors of MACEs. Nevertheless, following the adjustment for covariates, only the SIIRI was found to be a significant predictor MACEs and its corresponding specific endpoint occurrences. The predictive ability of the model was improved when six different inflammatory markers were added to the basic model established by traditional risk factors, namely, the C-index increased, and the SIIRI increased most significantly (AUC: 0.778; 95% CI: 0.743-0.812; p < .001). However, among the six novel inflammatory markers, only SIIRI had improved net reclassification improvement (NRI) and integrated discrimination improvement (IDI) (NRI: 0.187; 95% CI: 0.115-0.259, p < .001. IDI: 0.135; 95% CI: 0.111-0.159, p < .001), which was superior to the basic model established by traditional risk factors. CONCLUSIONS: SIIRI is independent predictor of MACEs in newly diagnosed CAD patients. SIIRI was superior to other measures in predicting MACEs. The combination of SIIRI and traditional risk factors can more accurately predict MACEs.
Assuntos
Biomarcadores , Doença da Artéria Coronariana , Inflamação , Linfócitos , Humanos , Doença da Artéria Coronariana/imunologia , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Masculino , Feminino , Pessoa de Meia-Idade , Linfócitos/imunologia , Prognóstico , Inflamação/diagnóstico , Inflamação/imunologia , Inflamação/sangue , Biomarcadores/sangue , Idoso , Angiografia Coronária , Neutrófilos/imunologia , Plaquetas/imunologia , Plaquetas/patologia , Fatores de Risco , SeguimentosRESUMO
BACKGROUND: Inflammation plays a pivotal role in atherogenesis and is a causal risk factor for atherosclerotic cardiovascular disease. Non-invasive coronary CT angiography (CCTA) enables evaluation of coronary plaque phenotype. This study investigates the relationship between a comprehensive panel of inflammatory markers and short-term plaque progression on serial CCTA imaging, hypothesising that inflammation is associated with increased plaque volume. METHODS: A total of 161 patients aged ≥40 years with stable multivessel coronary artery disease were included, who underwent CCTA at baseline and 12 months follow-up. Baseline plasma levels of interleukin 6 (IL-6), high-sensitivity C-reactive protein and other inflammatory markers were measured. Plaque volumes were assessed using semiautomated software, calculating total, noncalcified, calcified and low-attenuation noncalcified plaque volumes. Linear regression models, adjusted for ASSIGN score, segment involvement score and body mass index, evaluated associations between inflammatory markers and plaque volume changes. RESULTS: The mean±SD age was 65.4±8.4 years, with 129 (80.6%) male participants. Baseline total plaque volume was 1394 (1036, 1993) mm³. After 12 months, total plaque volume changed by 78 (-114, 244) mm³. IL-6 levels were associated with a 4.9% increase in total plaque volume (95% CI: 0.9 to 8.9, p=0.018) and a 4.8% increase in noncalcified plaque volume (95% CI: 0.7 to 8.9, p=0.022). No significant associations were observed for other inflammatory markers. CONCLUSIONS: Plasma IL-6 levels are significantly associated with increased total and noncalcified short-term plaque progression in patients with stable coronary artery disease. This supports the potential of IL-6 as a target for reducing plaque progression and cardiovascular risk.
Assuntos
Biomarcadores , Angiografia por Tomografia Computadorizada , Angiografia Coronária , Doença da Artéria Coronariana , Progressão da Doença , Interleucina-6 , Placa Aterosclerótica , Humanos , Masculino , Feminino , Interleucina-6/sangue , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/diagnóstico , Idoso , Placa Aterosclerótica/sangue , Biomarcadores/sangue , Pessoa de Meia-Idade , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/patologia , Fatores de Tempo , Fatores de Risco , Seguimentos , Estudos ProspectivosRESUMO
BACKGROUND: The value of physiological ischemia versus anatomic severity of disease for prognosis and management of patients with stable coronary artery disease (CAD) is widely debated. METHODS: A total of 1764 patients who had rest-stress cadmium-zinc-telluride single-photon emission computed tomography myocardial perfusion imaging and angiography (invasive or computed tomography) were prospectively enrolled and followed for cardiac death/nonfatal myocardial infarction. The CAD prognostic index (CADPI) was used to quantify the extent and severity of angiographic disease. Prognostic value was assessed using Cox models, adjusted for pretest risk, known CAD, stressor, left ventricular ejection fraction, %ischemia and infarct, CADPI, and early (90-day) revascularization. Incremental prognostic value was evaluated using net reclassification index. RESULTS: The mean age was 69.7±9.5 years, 24.4% were women, and 29.3% had known CAD. Significant ischemia (>10%) was present in 28.4%. Nonobstructive, single, and multivessel disease was present in 256 (14.5%), 772 (43.8%), and 736 (41.7%), respectively. Early revascularization occurred in 579 (32.8%). Cardiac death/myocardial infarction occurred in 148 (8.4%) over a 4.6-year median follow-up. Both %ischemia and CADPI provided independent and incremental prognostic value over pretest clinical risk (P<0.001). In a model containing both ischemia and anatomy, ischemia was prognostic (hazard ratio per 5% ↑, 1.35 [95% CI, 1.11-1.63]; P=0.002) but CADPI was not (hazard ratio per 10-unit ↑, 1.09 [95% CI, 0.99-1.20]; P=0.07). Early revascularization modified the risk associated with %ischemia (interaction P=0.003) but not with CADPI (interaction P=0.6). %Ischemia and single-photon emission computed tomography variables added incremental prognostic value over clinical risk and CADPI (net reclassification index, 20.3% [95% CI, 9%-32%]; P<0.05); however, CADPI was not incrementally prognostic beyond pretest risk, %ischemia, and single-photon emission computed tomography variables (net reclassification index, 3.1% [95% CI, -5% to 15%]; P=0.21). CONCLUSIONS: Ischemic burden provides independent and incremental prognostic value beyond CAD anatomy and identifies patients who benefit from early revascularization. The anatomic extent of disease has independent prognostic value over clinical risk factors but offers limited incremental benefit for prognosis and guiding revascularization beyond physiological severity (ischemia).
Assuntos
Angiografia Coronária , Doença da Artéria Coronariana , Imagem de Perfusão do Miocárdio , Revascularização Miocárdica , Humanos , Feminino , Masculino , Idoso , Revascularização Miocárdica/métodos , Imagem de Perfusão do Miocárdio/métodos , Estudos Prospectivos , Pessoa de Meia-Idade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/terapia , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/cirurgia , Prognóstico , Valor Preditivo dos Testes , Isquemia Miocárdica/fisiopatologia , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/mortalidade , Fatores de Risco , Índice de Gravidade de Doença , Tomografia Computadorizada de Emissão de Fóton Único , Medição de Risco , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/fisiopatologia , Angiografia por Tomografia Computadorizada , Fatores de TempoRESUMO
BACKGROUND: Sleep apnea (SA) has been linked to an increased risk of dementia in numerous observational studies; whether this is driven by neurodegenerative, vascular, or other mechanisms is not clear. We sought to examine the bidirectional causal relationships between SA, Alzheimer disease (AD), coronary artery disease (CAD), and ischemic stroke using Mendelian randomization. METHODS AND RESULTS: Using summary statistics from 4 recent, large genome-wide association studies of SA (n=523 366), AD (n=94 437), CAD (n=1 165 690), and stroke (n=1 308 460), we conducted bidirectional 2-sample Mendelian randomization analyses. Our primary analytic method was fixed-effects inverse variance-weighted (IVW) Mendelian randomization; diagnostics tests and sensitivity analyses were conducted to verify the robustness of the results. We identified a significant causal effect of SA on the risk of CAD (odds ratio [ORIVW]=1.35 per log-odds increase in SA liability [95% CI=1.25-1.47]) and stroke (ORIVW=1.13 [95% CI=1.01-1.25]). These associations were somewhat attenuated after excluding single-nucleotide polymorphisms associated with body mass index (ORIVW=1.26 [95% CI=1.15-1.39] for CAD risk; ORIVW=1.08 [95% CI=0.96-1.22] for stroke risk). SA was not causally associated with a higher risk of AD (ORIVW=1.14 [95% CI=0.91-1.43]). We did not find causal effects of AD, CAD, or stroke on risk of SA. CONCLUSIONS: These results suggest that SA increased the risk of CAD, and the identified causal association with stroke risk may be confounded by body mass index. Moreover, no causal effect of SA on AD risk was found. Future studies are warranted to investigate cardiovascular pathways between sleep disorders, including SA, and dementia.
Assuntos
Doença de Alzheimer , Estudo de Associação Genômica Ampla , Análise da Randomização Mendeliana , Síndromes da Apneia do Sono , Humanos , Doença de Alzheimer/genética , Doença de Alzheimer/epidemiologia , Doença de Alzheimer/diagnóstico , Síndromes da Apneia do Sono/genética , Síndromes da Apneia do Sono/epidemiologia , Síndromes da Apneia do Sono/complicações , Síndromes da Apneia do Sono/diagnóstico , Fatores de Risco , Polimorfismo de Nucleotídeo Único , Medição de Risco/métodos , Doença da Artéria Coronariana/genética , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/diagnóstico , Predisposição Genética para Doença , Doenças Cardiovasculares/genética , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , AVC Isquêmico/genética , AVC Isquêmico/epidemiologia , AVC Isquêmico/etiologiaRESUMO
BACKGROUND: Approximately 50% of women referred for invasive coronary angiography have angina and nonobstructive coronary arteries, which includes coronary microvascular dysfunction, vasospastic angina, and other vasomotor disorders. We sought to determine the real-world diagnostic yield of invasive coronary angiography and coronary function testing in women with angina and nonobstructive coronary arteries. METHODS AND RESULTS: From 2018 to 2023, we enrolled 198 women who underwent either coronary angiography (CA) alone (n=99) or coronary function testing (CFT; n=99). Mean±SD age was 62±10 years (CA alone) compared with 57±10 years (CFT). Coronary angiography was interpreted as nonobstructive coronary artery disease more frequently after CA alone (79% versus 52%). Of the women who underwent CFT, 82% (N=81) were found to have vasomotor disorders, including coronary microvascular dysfunction (27%), vasospastic angina (32%), mixed coronary microvascular dysfunction/vasospastic angina (16%), endothelial dysfunction (10%; without spasm), elevated resting flow (2%), or symptomatic myocardial bridging (4%). Compared with women undergoing CA alone, medications were changed more frequently after CFT at 24 hours (41% versus 65%; P=0.001) and between 24 hours and 30 days (30% versus 44%; P=0.04) with intensification of antianginal therapy (79% versus 92%; P<0.0001) and increased use of calcium channel blockers (36% versus 63%; P<0.0001). CONCLUSIONS: Our findings demonstrate that women presenting with suspected ischemic heart disease undergoing CA alone only received an anatomic diagnosis, whereas >80% of women undergoing CFT received a specific diagnosis of a coronary vasomotor disorder and greater intensification of antianginal therapy.
Assuntos
Angina Pectoris , Angiografia Coronária , Vasos Coronários , Humanos , Feminino , Pessoa de Meia-Idade , Angina Pectoris/fisiopatologia , Angina Pectoris/diagnóstico , Angina Pectoris/diagnóstico por imagem , Idoso , Vasos Coronários/fisiopatologia , Vasos Coronários/diagnóstico por imagem , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/diagnóstico por imagem , Testes de Função Cardíaca/métodos , Valor Preditivo dos Testes , Estudos Retrospectivos , Circulação Coronária/fisiologia , Vasoespasmo Coronário/fisiopatologia , Vasoespasmo Coronário/diagnóstico por imagem , Vasoespasmo Coronário/diagnósticoRESUMO
Coronary artery blood flow is influenced by various factors including vessel geometry, hemodynamic conditions, timing in the cardiac cycle, and rheological conditions. Multiple patterns of disturbed coronary flow may occur when blood flow separates from the laminar plane, associated with inefficient blood transit, and pathological processes modulated by the vascular endothelium in response to abnormal wall shear stress. Current simulation techniques, including computational fluid dynamics and fluid-structure interaction, can provide substantial detail on disturbed coronary flow and have advanced the contemporary understanding of the natural history of coronary disease. However, the clinical application of these techniques has been limited to hemodynamic assessment of coronary disease severity, with the potential to refine the assessment and management of coronary disease. Improved computational efficiency and large clinical trials are required to provide an incremental clinical benefit of these techniques beyond existing tools. This contemporary review is a clinically relevant overview of the disturbed coronary flow and its associated pathological consequences. The contemporary methods to assess disturbed flow are reviewed, including clinical applications of these techniques. Current limitations and future opportunities in the field are also discussed.
Assuntos
Doença da Artéria Coronariana , Circulação Coronária , Vasos Coronários , Modelos Cardiovasculares , Estresse Mecânico , Humanos , Circulação Coronária/fisiologia , Vasos Coronários/fisiopatologia , Vasos Coronários/diagnóstico por imagem , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/diagnóstico por imagem , Velocidade do Fluxo Sanguíneo/fisiologia , Hemodinâmica/fisiologia , Simulação por Computador , HidrodinâmicaRESUMO
The correlation between diabetes and coronary artery disease (CAD) is well established. Insulin resistance (IR) is considered a primary contributor to elevated CAD risk in diabetic individuals. The triglyceride-glucose (TyG) index serves as a straightforward surrogate marker for insulin resistance. However, few studies have explored their correlations with myocardial infarction and CAD severity. Therefore, our study aimed to investigate the association between the TyG index and the occurrence of myocardial infarction, as well as the severity of coronary artery disease. We conducted a retrospective study involving 3865 consecutive patients who underwent coronary angiography at the First Affiliated Hospital of Zhejiang University, School of Medicine. Of these, 1724 patients were diagnosed with coronary artery disease. Demographic, biochemical, clinical, and angiographic data were gathered. A robust correlation exists between the TyG index and CAD subtypes, suggesting its potential as an independent clinical diagnostic marker. Moreover, the TyG index exhibited a significant positive correlation with disease severity, as assessed by the Gensini score. Elevated TyG index was associated with an increased predisposition to severe CAD, as indicated by the Gensini score, and myocardial infarction, even after adjusting for well-established cardiovascular risk factors.
Assuntos
Glicemia , Angiografia Coronária , Doença da Artéria Coronariana , Índice de Gravidade de Doença , Triglicerídeos , Humanos , Masculino , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/diagnóstico , Triglicerídeos/sangue , Pessoa de Meia-Idade , Glicemia/análise , Glicemia/metabolismo , Estudos Retrospectivos , Idoso , Infarto do Miocárdio/sangue , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Biomarcadores/sangue , Resistência à Insulina , Fatores de RiscoRESUMO
INTRODUCTION: Lipoprotein(a) [Lp(a)] is linked to higher risks of atherosclerotic cardiovascular disease (ASCVD). Current guideline recommendations are quite liberal on measuring Lp(a) (Class IIa, Level C), and may lead to underuse among (interventional) cardiologists. AREAS COVERED: This case-based narrative review outlines four clinical cases of patients with elevated Lp(a) to illustrate its pathophysiological impact on coronary artery disease (CAD). The expert consensus statements from the American Heart Association (AHA) and European Atherosclerosis Society (EAS) served as the basis of this review. More recent publications, from 2023 to 2024, were accessed through the MEDLINE online library. EXPERT OPINION: We highlighted the importance of routine Lp(a) measurement in identifying patients at high risk for atherosclerosis, necessitating potent risk mitigation. Measuring Lp(a) helps clinicians identify which patients are at highest residual risk, who require potent pharmacological treatment and special attention during catheter interventions. As noninvasive and advanced intravascular imaging modalities evolve, future catheterization laboratories will integrate advanced imaging, diagnostics, and treatment, facilitating tailored patient care. Knowing Lp(a) levels is crucial in this context. While Lp(a)-lowering drugs are currently investigated in clinical trials, it is of paramount importance to know Lp(a) levels and strive toward aggressive management of other modifiable risk factors in patients with elevated Lp(a) and established symptomatic CAD being diagnosed or treated in catheterization laboratories.
Assuntos
Doença da Artéria Coronariana , Lipoproteína(a) , Humanos , Aterosclerose/sangue , Aterosclerose/diagnóstico , Biomarcadores/sangue , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/diagnóstico , Lipoproteína(a)/sangue , Guias de Prática Clínica como Assunto , Recidiva , Medição de Risco/métodos , Medição de Risco/normasRESUMO
BACKGROUND: Lipoprotein(a) [Lp(a)] plasma level is a well-known risk factor for coronary artery disease (CAD). Existing data regarding the influence of sex on the Lp(a)-CAD relationship are inconsistent. OBJECTIVE: To investigate the relationship between Lp(a) and CAD in men and women and to elucidate any sex-specific differences that may exist. METHODS: Data of patients with Lp(a) measurements who were admitted to a tertiary university hospital, Koc University Hospital, were analyzed. The relationship between Lp(a) levels and CAD was explored in all patients and in subgroups created by sex. Two commonly accepted Lp(a) thresholds ≥ 30 and ≥ 50 mg/dL were analyzed. RESULTS: A total of 1858 patients (mean age 54 ± 17 years; 53.33% females) were included in the analysis. Lp(a) was an independent predictor of CAD according to the multivariate regression model for the entire cohort. In all cohort, both cut-off values (≥ 30 and ≥ 50 mg/dL) were detected as independent predictors of CAD (p < 0.001). In sex-specific analysis, an Lp(a) ≥ 30 mg/dL was an independent predictor of CAD only in women (p < 0.001), but Lp(a) ≥ 50 mg/dL was a CAD predictor both in men and women (men, p = 0.004; women, p = 0.047). CONCLUSION: The findings of this study may suggest that different thresholds of Lp(a) level can be employed for risk stratification in women compared to men.