CT or Invasive Coronary Angiography in Stable Chest Pain.

BACKGROUND: In the diagnosis of obstructive coronary artery disease (CAD), computed tomography (CT) is an accurate, noninvasive alternative to invasive coronary angiography (ICA). However, the comparative effectiveness of CT and ICA in the management of CAD to reduce the frequency of major adverse cardiovascular events is uncertain. METHODS: We conducted a pragmatic, randomized trial comparing CT with ICA as initial diagnostic imaging strategies for guiding the treatment of patients with stable chest pain who had an intermediate pretest probability of obstructive CAD and were referred for ICA at one of 26 European centers. The primary outcome was major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) over 3.5 years. Key secondary outcomes were procedure-related complications and angina pectoris. RESULTS: Among 3561 patients (56.2% of whom were women), follow-up was complete for 3523 (98.9%). Major adverse cardiovascular events occurred in 38 of 1808 patients (2.1%) in the CT group and in 52 of 1753 (3.0%) in the ICA group (hazard ratio, 0.70; 95% confidence interval [CI], 0.46 to 1.07; P = 0.10). Major procedure-related complications occurred in 9 patients (0.5%) in the CT group and in 33 (1.9%) in the ICA group (hazard ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final 4 weeks of follow-up was reported in 8.8% of the patients in the CT group and in 7.5% of those in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48). CONCLUSIONS: Among patients referred for ICA because of stable chest pain and intermediate pretest probability of CAD, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy. (Funded by the European Union Seventh Framework Program and others; DISCHARGE ClinicalTrials.gov number, NCT02400229.).

Coronary Artery Calcium Score Predicts Major Adverse Cardiovascular Events in Stable Chest Pain.

Background Coronary artery calcium (CAC) has prognostic value for major adverse cardiovascular events (MACE) in asymptomatic individuals, whereas its role in symptomatic patients is less clear. Purpose To assess the prognostic value of CAC scoring for MACE in participants with stable chest pain initially referred for invasive coronary angiography (ICA). Materials and Methods This prespecified subgroup analysis from the Diagnostic Imaging Strategies for Patients With Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) trial, conducted between October 2015 and April 2019 across 26 centers in 16 countries, focused on adult patients with stable chest pain referred for ICA. Participants were randomly assigned to undergo either ICA or coronary CT. CAC scores from noncontrast CT scans were categorized into low, intermediate, and high groups based on scores of 0, 1-399, and 400 or higher, respectively. The end point of the study was the occurrence of MACE (myocardial infarction, stroke, and cardiovascular death) over a median 3.5-year follow-up, analyzed using Cox proportional hazard regression tests. Results The study involved 1749 participants (mean age, 60 years ± 10 [SD]; 992 female). The prevalence of obstructive coronary artery disease (CAD) at CT angiography rose from 4.1% (95% CI: 2.8, 5.8) in the CAC score 0 group to 76.1% (95% CI: 70.3, 81.2) in the CAC score 400 or higher group. Revascularization rates increased from 1.7% to 46.2% across the same groups (P < .001). The CAC score 0 group had a lower MACE risk (0.5%; HR, 0.08 [95% CI: 0.02, 0.30]; P < .001), as did the 1-399 CAC score group (1.9%; HR, 0.27 [95% CI: 0.13, 0.59]; P = .001), compared with the 400 or higher CAC score group (6.8%). No significant difference in MACE between sexes was observed (P = .68). Conclusion In participants with stable chest pain initially referred for ICA, a CAC score of 0 showed very low risk of MACE, and higher CAC scores showed increasing risk of obstructive CAD, revascularization, and MACE at follow-up. Clinical trial registration no. NCT02400229 © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Hanneman and Gulsin in this issue.

Impact of smoking in patients with suspected coronary artery disease in the randomised DISCHARGE trial.

OBJECTIVES: To investigate if the effect of cardiac computed tomography (CT) vs. invasive coronary angiography (ICA) on cardiovascular events differs based on smoking status. MATERIALS AND METHODS: This pre-specified subgroup analysis of the pragmatic, prospective, multicentre, randomised DISCHARGE trial (NCT02400229) involved 3561 patients with suspected coronary artery disease (CAD). The primary endpoint was major adverse cardiovascular events (MACE: cardiovascular death, non-fatal myocardial infarction, or stroke). Secondary endpoints included an expanded MACE composite (MACE, transient ischaemic attack, or major procedure-related complications). RESULTS: Of 3445 randomised patients with smoking data (mean age 59.1 years + / - 9.7, 1151 men), at 3.5-year follow-up, the effect of CT vs. ICA on MACE was consistent across smoking groups (p for interaction = 0.98). The percutaneous coronary intervention rate was significantly lower with a CT-first strategy in smokers and former smokers (p = 0.01 for both). A CT-first strategy reduced the hazard of major procedure-related complications (HR: 0.21, 95% CI: 0.03, 0.81; p = 0.045) across smoking groups. In current smokers, the expanded MACE composite was lower in the CT- compared to the ICA-first strategy (2.3% (8) vs 6.0% (18), HR: 0.38; 95% CI: 0.17, 0.88). The rate of non-obstructive CAD was significantly higher in all three smoking groups in the CT-first strategy. CONCLUSION: For patients with stable chest pain referred for ICA, the clinical outcomes of CT were consistent across smoking status. The CT-first approach led to a higher detection rate of non-obstructive CAD and fewer major procedure-related complications in smokers. CLINICAL RELEVANCE STATEMENT: This pre-specified sub-analysis of the DISCHARGE trial confirms that a CT-first strategy in patients with stable chest pain referred for invasive coronary angiography with an intermediate pre-test probability of coronary artery disease is as effective as and safer than invasive coronary angiography, irrespective of smoking status. TRIAL REGISTRATION: ClinicalTrials.gov NCT02400229. KEY POINTS: • No randomised studies have assessed smoking status on CT effectiveness in symptomatic patients referred for invasive coronary angiography. • A CT-first strategy results in comparable adverse events, fewer complications, and increased coronary artery disease detection, irrespective of smoking status. • A CT-first strategy is safe and effective for stable chest pain patients with intermediate pre-test probability for CAD, including never smokers.

Correction to: Pilot study of the multicentre DISCHARGE trial: image quality and protocol adherence results of computed tomography and invasive coronary angiography.

The original version of this article, published on 16 December 2019, unfortunately contained two mistakes.

Pilot study of the multicentre DISCHARGE Trial: image quality and protocol adherence results of computed tomography and invasive coronary angiography.

OBJECTIVE: To implement detailed EU cardiac computed tomography angiography (CCTA) quality criteria in the multicentre DISCHARGE trial (FP72007-2013, EC-GA 603266), we reviewed image quality and adherence to CCTA protocol and to the recommendations of invasive coronary angiography (ICA) in a pilot study. MATERIALS AND METHODS: From every clinical centre, imaging datasets of three patients per arm were assessed for adherence to the inclusion/exclusion criteria of the pilot study, predefined standards for the CCTA protocol and ICA recommendations, image quality and non-diagnostic (NDX) rate. These parameters were compared via multinomial regression and ANOVA. If a site did not reach the minimum quality level, additional datasets had to be sent before entering into the final accepted database (FADB). RESULTS: We analysed 226 cases (150 CCTA/76 ICA). The inclusion/exclusion criteria were not met by 6 of the 226 (2.7%) datasets. The predefined standard was not met by 13 of 76 ICA datasets (17.1%). This percentage decreased between the initial CCTA database and the FADB (multinomial regression, 53 of 70 vs 17 of 75 [76%] vs [23%]). The signal-to-noise ratio and contrast-to-noise ratio of the FADB did not improve significantly (ANOVA, p = 0.20; p = 0.09). The CTA NDX rate was reduced, but not significantly (initial CCTA database 15 of 70 [21.4%]) and FADB 9 of 75 [12%]; p = 0.13). CONCLUSION: We were able to increase conformity to the inclusion/exclusion criteria and CCTA protocol, improve image quality and decrease the CCTA NDX rate by implementing EU CCTA quality criteria and ICA recommendations. KEY POINTS: • Failure to meet protocol adherence in cardiac CTA was high in the pilot study (77.6%). • Image quality varies between sites and can be improved by feedback given by the core lab. • Conformance with new EU cardiac CT quality criteria might render cardiac CTA findings more consistent and comparable.

Carotid artery plaque composition and distribution: near-infrared spectroscopy and intravascular ultrasound analysis.

Most atherosclerotic plaques (APs) form in typical predilection areas of low endothelial shear stress (ESS). On the contrary, previous data hinted that plaques rupture in their proximal parts where accelerated blood flow causes high ESS. It was postulated that high ESS plays an important role in the latter stages of AP formation and in its destabilization. Here, we used near-infrared spectroscopy (NIRS) to analyse the distribution of lipid core based on the presumed exposure to ESS. A total of 117 carotid arteries were evaluated using NIRS and intravascular ultrasound (IVUS) prior to carotid artery stenting. The point of minimal luminal area (MLA) was determined using IVUS. A stepwise analysis of the presence of lipid core was then performed using NIRS. The lipid core presence was quantified as the lipid core burden index (LCBI) within 2 mm wide segments both proximally and distally to the MLA. The analysed vessel was then divided into three 20 mm long thirds (proximal, middle, and distal) for further analysis. The maximal value of LCBI (231.9 ± 245.7) was noted in the segment localized just 2 mm proximally to MLA. The mean LCBI in the middle third was significantly higher than both the proximal (121.4 ± 185.6 vs. 47.0 ± 96.5, P < 0.01) and distal regions (121.4 ± 185.6 vs. 32.4 ± 89.6, P < 0.01). Lipid core was more common in the proximal region when compared with the distal region (mean LCBI 47.0 ± 96.5 vs. 32.4 ± 89.6, P < 0.01).

Histopathological diagnosis of myocarditis.

Histopathological assessment of the endomyocardial biopsy represents a gold standard in diagnosis of myocarditis (MC). For a long time, the microscopic diagnosis relied on Dallas criteria. They defined MC on morphological grounds as a presence of inflammatory infiltrate accompanied by signs of myocyte damage. However, these criteria were abandoned due to large proportion of false negative results and substantial interpersonal variability in the histopathological evaluation. The immunohistochemistry was implemented in the diagnostic process as well. Morphological classification of MC is based on the type of the inflammatory infiltration. The most common type of MC in the routine bioptic practice is lymphocytic MC. Giant cell, granulomatous, neutrophilic and eozinophilic MC are less frequent. The aim of this work is to inform about the current level of knowledge in histopathological diagnostics of MC and, in relation to previous article “ Štěchovský, Adla, Bonaventura: Clinical perspective on the myocarditis and cardiomyopathies”, discuss also a different clinical and pathological view on this group of diseases.

Recent advances in microscopic diagnosis of cardiomyopathies.

A substantial proportion of cardiomyopathies (CMP) harbour non-specific microscopic findings and the diagnosis is based on the clinical phenotype. Therefore a majority of dilated and hypertrophic CMP are encountered by a pathologist as explanted hearts or during autopsy. The indication for the endomyocardial biopsy usually follows clinical suspicion for infiltrative disease and plays an important role in paediatric patients, where the metabolic CMP are more frequent. Due to suggestive microscopic appearance of these diseases, a histopathological examination represents an important part of the diagnostic algorithm. The biopsy is relevant especially in case of restrictive CMP, because this disease is often caused by amyloid depositions. In case of hypertrophic CMP, the endomyocardial biopsy is considered usually in paediatric population since the majority of storage and mitochondrial disorders manifest hypertrophic phenotype. Diagnosis of dilated CMP is based on the clinical grounds and the main task for the pathologist is to rule out myocarditis.

Clinical perspective on the myocarditis and cardiomyopathies.

Myocardial diseases are often encountered in cardiology and pose a significant diagnostic challenge. Myocarditis is an acute inflammatory disease of the heart muscle. Pathophysiology of myocarditis is a complex interplay of genetic background, innate immunity, viral or bacterial agents and formation of autoreactive antibodies and lymphocytes that maintain the inflammation after the infection was eliminated. Differentiation of myocardial infarction or heart failure of different etiology is crucial in the acute stage. Cardiac magnetic resonance imaging (MRI) enables with sufficient sensitivity and specificity diagnosis of myocardial inflammation and scar. Endomyocardial biopsy (EMB) with histology and immunohistochemistry is a gold standard for detection of myocarditis. EMB is indicated in selected patients with life-threatening symptoms where EMB may have therapeutic consequences. Giant cell myocarditis and eosinophilic myocarditis are specific examples of such a condition. Polymerase chain reaction (PCR) of the myocardial sample is used to detect viral genome. Serum antibodies or PCR from blood are not helpful in determining the etiology of myocarditis. Viral presence in myocardium is found in patients who do not have histological evidence of myocarditis which makes the association of positive PCR and etiology of myocarditis obscure. Cardiomyopathies (CMP) are characterized by structural and functional cardiac abnormalities that cannot be explained by coronary artery disease or abnormal loading conditions (valvular disease, arterial hypertension, congenital heart disease). CMP are classified based on the prevailing morphology regardless of primary (genetic, idiopathic) or secondary (systemic disease) etiology. European Society of Cardiology defines five types of CMP: hypertrophic, dilated, restrictive, arrhythmogenic and unclassified. CMP diagnosis is based on the imaging with echocardiography, coronary angiography, invasive hemodynamics and cardiac MRI. EMB is rarely indicated in dilated or restrictive CMP. Genetic testing is used to determine pathogenic mutations in phenotype positive patients and in familiar screening. Genetically determined CMP are mostly monogenic and autosomal dominant. Incomplete penetrance and variable expressivity cause variable or even negative phenotypes in genotype positive individuals. Genetic screening of a large number of genes and non-coding DNA results in findings of many variants of uncertain significance which make the interpretation of the genetic testing difficult.

[Detection of vulnerable atherosclerotic plaque with near-infrared spectroscopy: a systematic review]. / Význam vulnerabilních aterosklerotických plátu a moznosti jejich detekce pomocí intravaskulární spektroskopie.

The term vulnerable atherosclerotic plaque is used to describe an atherosclerotic lesion with a high probability of rupture and thrombosis causing an acute coronary event or stroke. Pathogenesis of the vulnerable plaque has been well described pathologically and on experimental models. Detection of vulnerable plaques in vivo has been limited so far. There has been lack of methods able to predict future event from certain lesion characteristics that were rigorously validated on prospective clinical trials. Intravascular near-infrared spectroscopy is a novel technique that has been intentionally developed for the identification of a lipid core within a plaque. Results from recent clinical trials seem promising. This review briefly summarizes current knowledge in the field of near-infrared spectroscopy.

Age and Computed Tomography and Invasive Coronary Angiography in Stable Chest Pain: A Prespecified Secondary Analysis of the DISCHARGE Randomized Clinical Trial.

Importance: The effectiveness and safety of computed tomography (CT) and invasive coronary angiography (ICA) in different age groups is unknown. Objective: To determine the association of age with outcomes of CT and ICA in patients with stable chest pain. Design, Setting, and Participants: The assessor-blinded Diagnostic Imaging Strategies for Patients With Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) randomized clinical trial was conducted between October 2015 and April 2019 in 26 European centers. Patients referred for ICA with stable chest pain and an intermediate probability of obstructive coronary artery disease were analyzed in an intention-to-treat analysis. Data were analyzed from July 2022 to January 2023. Interventions: Patients were randomly assigned to a CT-first strategy or a direct-to-ICA strategy. Main Outcomes and Measures: MACE (ie, cardiovascular death, nonfatal myocardial infarction, or stroke) and major procedure-related complications. The primary prespecified outcome of this secondary analysis of age was major adverse cardiovascular events (MACE) at a median follow-up of 3.5 years. Results: Among 3561 patients (mean [SD] age, 60.1 [10.1] years; 2002 female [56.2%]), 2360 (66.3%) were younger than 65 years, 982 (27.6%) were between ages 65 to 75 years, and 219 (6.1%) were older than 75 years. The primary outcome was MACE at a median (IQR) follow-up of 3.5 (2.9-4.2) years for 3523 patients (99%). Modeling age as a continuous variable, age, and randomization group were not associated with MACE (hazard ratio, 1.02; 95% CI, 0.98-1.07; P for interaction = .31). Age and randomization group were associated with major procedure-related complications (odds ratio, 1.15; 95% CI, 1.05-1.27; P for interaction = .005), which were lower in younger patients. Conclusions and Relevance: Age did not modify the effect of randomization group on the primary outcome of MACE but did modify the effect on major procedure-related complications. Results suggest that CT was associated with a lower risk of major procedure-related complications in younger patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02400229.

Comparative effectiveness of initial computed tomography and invasive coronary angiography in women and men with stable chest pain and suspected coronary artery disease: multicentre randomised trial.

OBJECTIVE: To assess the comparative effectiveness of computed tomography and invasive coronary angiography in women and men with stable chest pain suspected to be caused by coronary artery disease. DESIGN: Prospective, multicentre, randomised pragmatic trial. SETTING: Hospitals at 26 sites in 16 European countries. PARTICIPANTS: 2002 (56.2%) women and 1559 (43.8%) men (total of 3561 patients) with suspected coronary artery disease referred for invasive coronary angiography on the basis of stable chest pain and a pre-test probability of obstructive coronary artery disease of 10-60%. INTERVENTION: Both women and men were randomised 1:1 (with stratification by gender and centre) to a strategy of either computed tomography or invasive coronary angiography as the initial diagnostic test (1019 and 983 women, and 789 and 770 men, respectively), and an intention-to-treat analysis was performed. Randomised allocation could not be blinded, but outcomes were assessed by investigators blinded to randomisation group. MAIN OUTCOME MEASURES: The primary endpoint was major adverse cardiovascular events (MACE; cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke). Key secondary endpoints were an expanded MACE composite (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, transient ischaemic attack, or major procedure related complication) and major procedure related complications. RESULTS: Follow-up at a median of 3.5 years was available in 98.9% (1979/2002) of women and in 99.0% (1544/1559) of men. No statistically significant gender interaction was found for MACE (P=0.29), the expanded MACE composite (P=0.45), or major procedure related complications (P=0.11). In both genders, the rate of MACE did not differ between the computed tomography and invasive coronary angiography groups. In men, the expanded MACE composite endpoint occurred less frequently in the computed tomography group than in the invasive coronary angiography group (22 (2.8%) v 41 (5.3%); hazard ratio 0.52, 95% confidence interval 0.31 to 0.87). In women, the risk of having a major procedure related complication was lower in the computed tomography group than in the invasive coronary angiography group (3 (0.3%) v 21 (2.1%); hazard ratio 0.14, 0.04 to 0.46). CONCLUSION: This study found no evidence for a difference between women and men in the benefit of using computed tomography rather than invasive coronary angiography as the initial diagnostic test for the management of stable chest pain in patients with an intermediate pre-test probability of coronary artery disease. An initial computed tomography scan was associated with fewer major procedure related complications in women and a lower frequency of the expanded MACE composite in men. TRIAL REGISTRATION: NCT02400229ClinicalTrials.gov NCT02400229.

Long-term changes after carotid stenting assessed by intravascular ultrasound and near-infrared spectroscopy.

BACKGROUND: Long-term effect of carotid stenting (CAS) on the stabilization of the plaque is almost unrecognized. Vascular healing and remodeling might seal the atherosclerotic plaque with neointimal hyperplasia decreasing the vulnerability. We aimed to assess long-term change in the lipid signal, stent and luminal dimensions and restenosis after CAS with the intravascular ultrasound (IVUS) and near-infrared spectroscopy (NIRS) imaging. METHODS: We performed follow-up angiography and NIRS-IVUS imaging of 58 carotid stents in 52 patients. Median time from CAS to the follow-up examination was 31 months (range, 5-56). The lipid signal of the stented segment was calculated from a NIRS-derived chemogram (a spectroscopic map) as the lipid core burden index (LCBI, a dimensionless number from 0 to 1,000). Planimetric and volumetric measurements from IVUS were performed to assess change in minimal stent area (MSA), minimal luminal area (MLA), stent and luminal volume, late stent expansion and percentage in-stent restenosis (ISR) volume. RESULTS: During the follow-up period, the mean (±SD) LCBI significantly decreased from 32±56 to 17±27 (P=0.002). The mean stent volume significantly increased from 717±302 to 1,019±429 mm3 (P<0.001) with mean stent expansion 43%±24%. The mean luminal volume increased from 717±302 to 760±359 mm3 (P=0.025) due to ISR encroaching 26%±15% of the stent volume. CONCLUSIONS: Lipid signal decreased during the follow-up period suggesting stabilization of the plaque. Late stent expansion was balanced with neointimal hyperplasia. TRIAL REGISTRATION: The trial is registered under clinicaltrials.gov NCT03141580.

Long-term survival of carotid stenting patients with regard to single- or double-vessel carotid artery disease: a propensity score matching analysis.

INTRODUCTION: There is lack of long-term data outside of controlled clinical trials in carotid artery stenting (CAS). In this study, we compared the short-term outcome, long-term survival, and rate of re-interventions for restenosis in patients after CAS, related to the extent of carotid atherosclerosis classified as single-vessel (unilateral) or double-vessel (bilateral) carotid artery disease. MATERIAL AND METHODS: We retrospectively evaluated 599 patients with significant carotid artery stenosis, who underwent 763 CAS procedures, and used the propensity score to match 226 pairs (452 patients) in the single- or double-vessel carotid disease. RESULTS: There was no significant difference in the occurrence of in-hospital major adverse events (3.5% vs. 3.1% of patients in the double-vessel carotid group vs. the single-vessel carotid group; p = 1) The mean follow-up was 6.1 ±4.0 years, and a total of 181 (40%) deaths occurred during 2759 patient-years, which translates into 7.8 and 5.3 deaths per 100 patient-years in the double-vessel carotid group and the single-vessel carotid group, respectively (p < 0.01). The survival in the double-vessel carotid group vs. the single-vessel carotid group at 10 years was 46% (95% CI: 38-54%) vs. 55% (95% CI: 47-63%) (p < 0.01). Twenty-four (11%) patients and 6 (3%) patients underwent re-interventions for restenosis in the double-vessel and the single-vessel carotid disease group, respectively (p < 0.01). CONCLUSIONS: Patients with CAS and significant double-vessel carotid artery disease had similar peri-procedural risk, but had a worse long-term survival, and a higher rate of re-interventions for restenosis compared to the single-vessel carotid artery disease patients.

MicroRNA-331 and microRNA-151-3p as biomarkers in patients with ST-segment elevation myocardial infarction.

We sought to analyse plasma levels of peripheral blood microRNAs (miRs) as biomarkers of ST-segment-elevation myocardial infarction (STEMI) due to type-1 myocardial infarction as a model situation of vulnerable plaque (VP) rupture. Samples of 20 patients with STEMI were compared both with a group of patients without angina pectoris in whom coronary angiogram did not reveal coronary atherosclerotic disease (no coronary atherosclerosis-NCA) and a group of patients with stable angina pectoris and at least one significant coronary artery stenosis (stable coronary artery disease-SCAD). This study design allowed us to identify miRs deregulated in the setting of acute coronary artery occlusion due to VP rupture. Based on an initial large scale miR assay screening, we selected a total of 12 miRs (three study miRs and nine controls) that were tested in the study. Two of the study miRs (miR-331 and miR-151-3p) significantly distinguished STEMI patients from the control groups, while ROC analysis confirmed their suitability as biomarkers. Importantly, this was observed in patients presenting early with STEMI, even before the markers of myocardial necrosis (cardiac troponin I, miR-208 and miR-499) were elevated, which suggests that the origin of miR-331 and miR-151-3p might be in the VP. In conclusion, the study provides two novel biomarkers observed in STEMI, which may be associated with plaque rupture.

Effect of stenting on the near-infrared spectroscopy-derived lipid core burden index of carotid artery plaque.

AIMS: Catheter-based intravascular near-infrared spectroscopy (NIRS) detects a lipid signal from atherosclerotic plaque. The aim of this study was to describe the effect of carotid artery stenting (CAS) on the lipid signal in a carotid stenosis. METHODS AND RESULTS: We performed NIRS combined with intravascular ultrasound (IVUS) during 120 CAS procedures. Minimal luminal area (MLA) and plaque burden (PB) at the site of MLA were measured with IVUS and lipid core burden index (LCBI), maximal LCBI in a 4 mm segment of the artery (LCBImax) and LCBI in a 4 mm segment at the site of MLA (LCBImla) with NIRS-derived chemograms. NIRS-IVUS imaging was performed at baseline, after stent implantation and after balloon post-dilatation. The most common lesion type was the fibrocalcific plaque (76%). Lipid-rich plaque (LCBImax ≥400) was present in 33% of carotid stenoses and in 20% at the site of MLA. Median MLA increased significantly from baseline to stent implantation (3.63 mm2 to 5.56 mm2, p<0.001) and to post-dilatation (5.56 mm2 to 12.03 mm2, p<0.001). Median LCBI, LCBImax and LCBImla significantly decreased from baseline to stent implantation: LCBI (60 to 8, p<0.001), LCBImax (294 to 60, p<0.001) and LCBImla (124 to 0, p<0.001). Post-dilatation of the stent had no further significant effect on median LCBI (8 to 5, p=0.890), LCBImax (60 to 50, p=0.690) and LCBImla (0 to 0, p=0.438). CONCLUSIONS: Carotid artery stenting significantly reduced the NIRS-derived lipid core burden index at the stented segment.

Mechanical Chest Compressions in Prolonged Cardiac Arrest due to ST Elevation Myocardial Infarction Can Cause Myocardial Contusion.

Acute coronary syndrome is a common cause of sudden cardiac death. We present a case report of a 60-year-old man without a history of coronary artery disease who presented with ST-elevation myocardial infarction. During transportation to the hospital, he developed ventricular fibrillation (VF) and later pulseless electrical activity. Chest compressions with LUCAS 2 (Medtronic, Minneapolis, MN) automated mechanical compression-decompression device were initiated. Coronary angiography showed total occlusion of the left main coronary artery and primary percutaneous coronary intervention (PCI) was performed. After the PCI, his heart started to generate effective contractions and LUCAS could be discontinued. Return of spontaneous circulation was achieved after 90 minutes of cardiac arrest. The patient died of cardiogenic shock 11 hours later. An autopsy revealed a transmural anterolateral myocardial infarction but also massive subepicardial hemorrhage and interstitial edema and hemorrhages on histologic samples from regions of the myocardium outside the infarction itself and also from the right ventricle. These lesions were concluded to be a myocardial contusion. The true incidence of myocardial contusion as a consequence of mechanical chest compressions is not known. We speculate that severe myocardial contusion might have influenced outcome of our patient.

Near-infrared spectroscopy combined with intravascular ultrasound in carotid arteries.

Limited insights into the pathophysiology of the atherosclerotic carotid stenosis are available in vivo. We conducted a prospective study to assess safety and feasibility of intravascular ultrasound (IVUS) combined with near-infrared spectroscopy (NIRS) in carotid arteries. In addition, we described the size and the distribution of lipid rich plaques in significant atherosclerotic carotid stenoses. In a prospective single centre study 45 consecutive patients (mean age 66 ± 8 years) with symptomatic (≥50 %) or asymptomatic (≥70 %) stenosis of internal carotid artery (ICA) amendable to carotid stenting were enrolled. A 40 mm long NIRS-IVUS pullback through the stenosis was performed. IVUS and NIRS data were analyzed to assess minimal luminal area (MLA), plaque burden (PB), remodeling index (RI), calcifications, lipid core burden index (LCBI), maximal LCBI in any 4 mm segment of the artery (LCBImx) and LCBI in the 4 mm segment at the site of minimal luminal area (LCBImxMLA). NIRS-IVUS pullbacks were safely performed without overt clinical events. LCBImx was significantly higher than LCBImxMLA (369.1 ± 221.1 vs. 215.7 ± 2589; p = 0.004). Conversely, PB was significantly larger at the site of MLA (87.4 ± 4.8 % vs. 58.3 ± 18.2 %; p < 0001). Distance of the NIRS-IVUS frame with the highest LCBI from the site of MLA was 6.5 ± 7.7 mm. Eighty percent of frames with maximal LCBI were localized within 10 mm from the site of MLA and 67 % proximally to or at the site of MLA. This study suggested safety and feasibility of the NIRS-IVUS imaging of the carotid stenosis and provided insights on the distribution of lipids in the carotid stenosis. Lipid rich plaques were more often located in the sites with a milder stenosis and smaller plaque burden than at the site of MLA.

The role of near-infrared spectroscopy in the detection of vulnerable atherosclerotic plaques.

Coronary artery disease is the leading cause of mortality worldwide. Most acute coronary syndromes are caused by a rupture of a vulnerable atherosclerotic plaque which can be characterized by a lipid-rich necrotic core with an overlying thin fibrous cap. Many vulnerable plaques can cause angiographically mild stenoses due to positive remodelling, which is why the extent of coronary artery disease may be seriously underestimated. In recent years, we have witnessed a paradigm shift in interventional cardiology. We no longer focus solely on the degree of stenosis; rather, we seek to determine the true extent of atherosclerotic disease. We seek to identify high-risk plaques for improvement in risk stratification of patients and prevention. Several imaging methods have been developed for this purpose. Intracoronary near-infrared spectroscopy is one of the most promising. Here, we discuss the possible applications of this diagnostic method and provide a comprehensive overview of the current knowledge.

Impact of coexisting multivessel coronary artery disease on short-term outcomes and long-term survival of patients treated with carotid stenting.

INTRODUCTION: Systemic atherosclerosis can result in both coronary artery disease (CAD) and carotid artery disease. Recently it has been shown that patients with CAD have a higher incidence of microembolization during carotid artery stenting (CAS), and it has been hypothesized that they could be at higher risk in this intervention. MATERIAL AND METHODS: We retrospectively evaluated an institutional registry with 437 consecutive patients who underwent coronary angiography and CAS to evaluate their short-term outcomes and long-term survival with regard to the presence of coexisting multivessel coronary artery disease (MVD). RESULTS: We performed 220 CAS procedures in MVD patients and 318 CAS procedures in non-MVD patients. The incidence of in-hospital CAS-related adverse events was 2.7% and 2.5% in the MVD and non-MVD groups, respectively (p = 0.88). At 30 days, there was no significant difference between the groups in terms of the number of patients with adverse events (hierarchically death/stroke/myocardial infarction; 8.8% vs. 5.5%; p = 0.18). The median duration of follow-up was 4.23 years. Survival free of all-cause mortality at 1, 3 and 5 years was 90% (95% CI: 86-94%), 79% (95% CI: 73-85%) and 70% (95% CI: 64-77%), and 92% (95% CI: 89-95%), 85% (95% CI: 80-90%) and 76% (95% CI: 70-82%) for the MVD and non-MVD groups (p = 0.02), respectively. CONCLUSIONS: These results suggest that patients with MVD combined with carotid artery disease are probably not at higher risk of early post-CAS adverse clinical events, but they have significantly worse long-term survival rates.