Optical frequency domain imaging-guided versus intravascular ultrasound-guided percutaneous coronary intervention for acute coronary syndromes: the OPINION ACS randomised trial.

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).

Role of S100ß in Unstable Angina Pectoris: Insights from Quantitative Flow Ratio.

BACKGROUND AND OBJECTIVE: Disturbed autonomic nervous system (ANS) may promote inflammatory, immune, and oxidative stress responses, which may increase the risk of acute coronary events. S100ß has been proposed as a biomarker of neuronal injury that would provide an insightful understanding of the crosstalk between the ANS, immune-inflammatory cells, and plaques that drive atherosclerosis. This study investigates the correlation between S100ß, and functional coronary stenosis as determined by quantitative flow ratio (QFR). METHODS: Patients with unstable angina pectoris (UAP) scheduled for coronary angiography and QFR were retrospectively enrolled. Serum S100ß levels were determined by enzyme-linked immunosorbent assay. The Gensini score was used to estimate the extent of atherosclerotic lesions and the cumulative sum of three-vessel QFR (3V-QFR) was calculated to estimate the total atherosclerotic burden. RESULTS: Two hundred thirty-three patients were included in this study. Receiver operator characteristic (ROC) curve indicated that S100ß>33.28 pg/mL predicted functional ischemia in patients with UAP. Multivariate logistic analyses showed that a higher level of S100ß was independently correlated with a functional ischemia-driven target vessel (QFR ≤0.8). This was also closely correlated with the severity of coronary lesions, as measured by the Gensini score (OR = 5.058, 95% CI: 2.912-8.793, p <0.001). According to 3V-QFR, S100ß is inversely associated with total atherosclerosis burden (B = -0.002, p <0.001). CONCLUSIONS: S100ß was elevated in the functional ischemia stages of UAP. It was independently associated with coronary lesion severity as assessed by Gensini score and total atherosclerosis burden as estimated by 3V-QFR in patients with UAP.

A comparative study examining the impact of coronary artery bypass grafting surgery with non-extracorporeal circulation on heart function and structure in patients with various forms of coronary heart diseases.

The aim of this study is to assess alterations in heart function and structure in patients diagnosed with non-ST segment elevation acute myocardial infarction (NSTEAMI), unstable angina (UA), and stable angina (SA) 1 year after undergoing off-pump coronary artery bypass grafting (OPCABG) performed without extracorporeal circulation. A total of 182 patients who underwent OPCABG were included and classified into 3 groups based on their preoperative diagnosis: the NSTEAMI group (n = 68), the UA group (n = 64), and the SA group (n = 50). Cardiac ultrasonography data were collected for all groups both preoperatively and 1 year postoperatively. Clinical data were subjected to statistical analysis. In the NSTEAMI group, postoperative observations revealed increases in left ventricular stroke volume and left ventricular end-systolic diameter, along with reductions in left ventricular end-diastolic volume (LVEDV) and left ventricular end-diastolic diameter (LVEDD) 1-year post-surgery. The UA group demonstrated decreases in LVEDV and LVEDD 1-year post-surgery. Similarly, the SA group exhibited an increase in left ventricular ejection fraction (LVEF) and reductions in LVEDV and LVEDD 1-year post-surgery. Comparative analysis of cardiac ultrasonography data revealed that the NSTEAMI group displayed significantly lower left ventricular stroke volume and notably higher left ventricular end-systolic diameter and volume compared to the UA and SA groups 1-year post-surgery. Furthermore, the SA group exhibited significantly elevated LVEF compared to the UA and NSTEAMI groups 1-year post-surgery. Cardiac ultrasonography findings indicate that all 3 groups exhibited improvements in cardiac function and left ventricular structure 1-year post-surgery. However, the NSTEAMI group demonstrated more substantial improvements in comparison to the UA and SA groups.

Prognostic value of a novel artificial intelligence-based coronary CTA-derived ischemia algorithm among patients with normal or abnormal myocardial perfusion.

BACKGROUND: Among patients with obstructive coronary artery disease (CAD) on coronary computed tomography angiography (CTA), downstream positron emission tomography (PET) perfusion imaging can be performed to assess the presence of myocardial ischemia. A novel artificial-intelligence-guided quantitative computed tomography ischemia algorithm (AI-QCTischemia) aims to predict ischemia directly from coronary CTA images. We aimed to study the prognostic value of AI-QCTischemia among patients with obstructive CAD on coronary CTA and normal or abnormal downstream PET perfusion. METHODS: AI-QCTischemia was calculated by blinded analysts among patients from the retrospective coronary CTA cohort at Turku University Hospital, Finland, with obstructive CAD on initial visual reading (diameter stenosis ≥50%) being referred for downstream 15O-H2O-PET adenosine stress perfusion imaging. All coronary arteries with their side branches were assessed by AI-QCTischemia. Absolute stress myocardial blood flow ≤2.3 â€‹ml/g/min in ≥2 adjacent segments was considered abnormal. The primary endpoint was death, myocardial infarction, or unstable angina pectoris. The median follow-up was 6.2 [IQR 4.4-8.3] years. RESULTS: 662 of 768 (86%) patients had conclusive AI-QCTischemia result. In patients with normal 15O-H2O-PET perfusion, an abnormal AI-QCTischemia result (n â€‹= â€‹147/331) vs. normal AI-QCTischemia result (n â€‹= â€‹184/331) was associated with a significantly higher crude and adjusted rates of the primary endpoint (adjusted HR 2.47, 95% CI 1.17-5.21, p â€‹= â€‹0.018). This did not pertain to patients with abnormal 15O-H2O-PET perfusion (abnormal AI-QCTischemia result (n â€‹= â€‹269/331) vs. normal AI-QCTischemia result (n â€‹= â€‹62/331); adjusted HR 1.09, 95% CI 0.58-2.02, p â€‹= â€‹0.794) (p-interaction â€‹= â€‹0.039). CONCLUSION: Among patients with obstructive CAD on coronary CTA referred for downstream 15O-H2O-PET perfusion imaging, AI-QCTischemia showed incremental prognostic value among patients with preserved perfusion by 15O-H2O-PET imaging, but not among those with reduced perfusion.

The role of computed tomography angiography in assessing the correlation between properties of coronary atherosclerotic plaque and blood lipids.

BACKGROUND: Coronary atherosclerotic heart disease (CAHD) is the leading cause of death in developed countries. OBJECTIVE: This study aimed to explore the correlation between the properties of coronary atherosclerotic plaque and blood lipids using computed tomography angiography (CTA). METHODS: A total of 83 patients with coronary heart disease were included in this study (males: 50; females: 33; average age: [59 ± 8] years old). They were classified into the stable angina group and unstable angina group. Atherosclerotic plaques were classified as fatty plaques (soft plaques), fibrous plaques, and calcified plaques based on the computed tomography (CT) values. SPSS 17.0 statistical software was used to analyze the correlation between the properties of angina and the CT values of atherosclerotic plaques, blood lipids, and plaque properties, and then compared between the stable and unstable angina groups. RESULTS: There were statistically significant differences in plaque properties between the stable and unstable angina groups (P< 0.001). During CTA examination, we found statistically significant differences in the CT density values of atherosclerotic plaques between the stable and unstable angina groups (P< 0.001). There were statistically significant differences between the properties of angina and the level of blood lipids (P< 0.05). CONCLUSION: Anginal properties negatively correlated with calcified plaques and positively correlated with non-calcified plaques. Calcified plaques negatively correlated with total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and triglycerides (TG), and positively correlated with high-density lipoprotein cholesterol (HDL-C). Non-calcified plaques negatively correlated with HDL-C and positively correlated with TC, LDL-C, and TG.

Relationship between Increased Plasma Levels of Legumain and Properties of Coronary Atherosclerotic Plaque. / Relação entre Níveis Plasmáticos Aumentados de Legumain e Propriedades da Placa Aterosclerótica Coronária.

BACKGROUND: Many clinical studies have confirmed that legumain is closely related to atherosclerosis. Unfortunately, different conclusions have been reached, and analyses and studies on atherosclerotic plaque characteristics in patients with increased plasma levels of legumain are still lacking. OBJECTIVES: This study aimed to investigate the correlation between legumain and coronary atherosclerotic plaque characteristics. METHODS: A total of 81 patients with coronary atherosclerotic heart disease (CHD), including 43 patients with unstable angina (UA) and 38 patients with stable angina (SA), were screened by coronary angiography. Intravascular ultrasound (IVUS) was performed to evaluate the characteristics of coronary atherosclerotic plaques, and plasma legumain levels were also measured. Values of p < 0.05 were considered significant. RESULTS: Legumain concentration was significantly higher in the two CHD subgroups than in the control group (all p<0.001). Legumain concentrations in the UA group were significantly higher than in the SA group (p=0.001). The plaque area, remodeling index (RI), and eccentricity index (EI) in the UA group were significantly higher than those in the SA group (p<0.001, p=0.001, p=0.001, respectively). There was a significant positive correlation between legumain levels and RI and EI in both UA and SA patients (all p<0.05). CONCLUSIONS: High plasma levels of legumain were closely related to the occurrence and severity of CHD, and the lesions tended to be unstable. Legumain is expected to be a potential inflammatory biomarker for the diagnosis of CHD and the early identification of unstable coronary lesions.

FUNDAMENTO: Muitos estudos clínicos confirmaram que a legumain está intimamente relacionada à aterosclerose. Infelizmente, chegaram-se a conclusões diferentes e ainda faltam análises e estudos sobre as características da placa aterosclerótica em pacientes com níveis plasmáticos aumentados de legumain. OBJETIVOS: Este estudo teve como objetivo investigar a correlação entre as características da legumain e da placa aterosclerótica coronariana. MÉTODOS: Um total de 81 pacientes com doença cardíaca aterosclerótica coronariana (DCAC), incluindo 43 pacientes com angina instável (AI) e 38 pacientes com angina estável (AE), foram examinados por angiografia coronária. Foi realizado ultrassom intravascular (IVUS) para avaliar as características das placas ateroscleróticas coronarianas, e os níveis plasmáticos de legumain também foram medidos. Valores de p < 0,05 foram considerados significativos. RESULTADOS: A concentração de legumain foi significativamente maior nos dois subgrupos de doença coronariana do que no grupo controle (todos p<0,001). As concentrações de legumain no grupo AI foram significativamente maiores do que no grupo SA (p=0,001). A área de placa, o índice de remodelamento (IR) e o índice de excentricidade (IE) no grupo AI foram significativamente maiores do que no grupo AE (p<0,001, p=0,001, p=0,001, respectivamente). Houve uma correlação positiva significativa entre os níveis de legumain e IR e IE em pacientes com AI e AE (todos p<0,05). CONCLUSÕES: Níveis plasmáticos elevados de legumain estavam intimamente relacionados com a ocorrência e gravidade da doença coronariana, e as lesões tendiam a ser instáveis. Espera-se que a legumain seja um potencial biomarcador inflamatório para o diagnóstico de doença coronariana e a identificação precoce de lesões coronárias instáveis.

One-year outcomes of patients undergoing percutaneous coronary intervention with the revived directional coronary atherectomy catheter: Insights from the J-PCI OUTCOME registry.

OBJECTIVES: We sought to investigate the 1-year outcomes, including all-cause and cardiovascular mortality, major adverse cardiovascular events (MACEs), and major bleeding, of patients undergoing percutaneous coronary intervention (PCI) with or without the revived directional coronary atherectomy (DCA) catheter in a Japanese nationwide registry. BACKGROUND: Clinical data regarding the midterm outcomes of patients undergoing PCI with DCA are scarce in contemporary real-world practice. METHODS: We analyzed the data of 74,764 patients who underwent PCI at 179 hospitals from January 2017 to December 2018. The baseline characteristics and 1-year outcomes of patients with stable coronary artery disease or unstable angina who underwent PCI with or without DCA were assessed. RESULTS: Overall, 431 patients (0.6%) underwent PCI with DCA. Patients in the DCA group were younger and predominantly male, with fewer comorbidities than patients in the non-DCA group. Stentless PCI with DCA following additional drug-coated balloon (DCB) angioplasty was the dominant strategy in the DCA group (43.6%). One-year outcomes, including all-cause mortality (1.2% in the DCA group vs. 2.5% in the non-DCA group, respectively, p = 0.075), cardiovascular death (0.9% vs. 1.0%, p = 0.69), MACEs (1.9% vs. 1.8%, p = 0.96), and nonfatal major bleeding requiring readmission (1.2% vs. 1.4%, p = 0.62), were comparable between the two groups. In the DCA group, 1-year outcomes were comparable, regardless of whether the stent or DCB was used. CONCLUSIONS: One-year clinical outcomes after PCI with DCA in patients with stable coronary artery disease or unstable angina are acceptable, regardless of stent use.

Immature neutrophil is associated with coronary plaque vulnerability based on optical coherence tomography analysis.

INTRODUCTION: High neutrophil to lymphocyte ratio is considered to predict poor prognosis of acute coronary syndrome (ACS). However, the association of neutrophil subpopulation with plaque vulnerability and the incidence of ACS remains unknown. METHODS AND RESULTS: Blood samples from 48 patients with unstable angina (UA), 31 with ST-segment elevation myocardial infarction (STEMI) and 33 healthy controls were collected at admission. The morphology of coronary plaques in 48 UA patients were further evaluated by optical coherence tomography (OCT). According to maturation stages of neutrophils and the expression of CD10 and CD101, circulating neutrophils could be divided into pre-neutrophils (CD101-CD10-), immature neutrophils (CD101+CD10-) and mature neutrophils (CD101+CD10+). While the number of pre-neutrophil was quite low in blood and comparable among three groups, the absolute counts and percentage of CD10- immature neutrophils were higher in peripheral bloods of UA and STEMI patients compared with those in healthy controls. The concentration of plasma myeloperoxidase was positively associated with the percentage of CD10- immature neutrophils. Furthermore, UA patients with thin-cap fibroatheroma (TCFA) observed by OCT had a higher proportion and larger number of immature neutrophils as compared to those without TCFA. The percentage of immature neutrophils also closely correlated with plaque rupture and the feature of vulnerable plaque, including thinner fibrous cap and larger lipid core, but did not associate with percent lumen stenosis. CONCLUSION: Our findings emphasize that the abnormally increased level of CD10- immature neutrophils may sever as a promising marker of the incidence of ACS and plaque vulnerability.

Revascularization outcomes in diabetic patients presenting with acute coronary syndrome with non-ST elevation.

BACKGROUND: To compare the outcomes of diabetic patients hospitalized with non-ST elevation myocardial infarction (NSTEMI) or unstable angina (UA) referred for revascularization by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in a real-life setting. METHODS: The study included 1987 patients with diabetes mellitus enrolled from the biennial Acute Coronary Syndrome Israeli Survey between 2000 and 2016, who were hospitalized for NSTEMI or UA, and underwent either PCI (N = 1652, 83%) or CABG (N = 335, 17%). Propensity score-matching analysis compared all-cause mortality in 200 pairs (1:1) who underwent revascularization by either PCI or CABG. RESULTS: Independent predictors for CABG referral included 3-vessel coronary artery disease (OR 4.9, 95% CI 3.6-6.8, p < 0.001), absence of on-site cardiac surgery (OR 1.4, 95% CI 1.1-1.9, p = 0.013), no previous PCI (OR 1.5, 95% CI 1.1-2.2, p = 0.024) or MI (OR 1.7, 95% CI 1.2-2.6, p = 0.002). While at 2 years of follow-up, survival analysis revealed no differences in mortality risk between the surgical and percutaneous revascularization groups (log-rank p = 0.996), after 2 years CABG was associated with a significant survival benefit (HR 1.53, 95% CI 1.07-2.21; p = 0.021). Comparison of the propensity score matching pairs also revealed a consistent long-term advantage toward CABG (log-rank p = 0.031). CONCLUSIONS: In a real-life setting, revascularization by CABG of diabetic patients hospitalized with NSTEMI/UA is associated with better long-term outcomes. Prospective randomized studies are warranted in order to provide more effective recommendations in future guidelines.

Predictors and morphological properties of culprit healed plaques in patients with angina pectoris.

BACKGROUND: Plaque healing may serve a vital function in the natural progression of atherosclerotic disease. This study sought to investigate predictors and morphological characteristics of healed plaque (HP) among angina pectoris (AP) patients. METHODS: Patients who presented with AP and received preintervention optical coherence tomography (OCT) imaging were consecutively selected for this single-center retrospective observational study. Patient's demographic and clinical information was collected from the hospital's electronic medical records. Coronary angiograms and OCT images were compared via offline software. RESULTS: A total of 390 patients were chosen as the final study population. HP was identified in 186 patients (47.7%) and was relatively less in cases of unstable angina pectoris (UAP) than in stable angina pectoris (SAP) (89/233 [38.2%] vs. 97/157[61.8%]). The HP group had greater prevalence rates of previous myocardial infarction and SAP and higher levels of triglycerides and uremia (median, 1.67 vs. 1.31 mmol/L [p = .01] and 364.22 ± 91.80 vs. 341.53 ± 77.64 µmol/L [p = .01], respectively). Using multivariate analysis, SAP and long lesion length were shown to be stand-alone indicators of HP. HP presented with more severe stenosis as well as a longer lesion length and had more vulnerable and more complex features. In HP lesions, UAP patients had more plaque ruptures and thrombosis, whereas SAP patients had lower uric acid levels and more multiple HPs(≥3 HPs). CONCLUSION: Clinical presentation of SAP and long lesion length were strong predictors for HP in patients with AP. Patients with HP presented with more severe stenosis, longer lesion lengths, greater inflammation, and vulnerability.

The association between SYNTAX score and long-term outcomes in patients with unstable angina pectoris: a single-centre retrospective study.

BACKGROUND: The SYNTAX score affects clinical outcomes in early studies. However, the prognostic value of the SYNTAX Score for long-term outcomes and differences by SYNTAX score risk stratification in long-term prognosis between medical therapy and percutaneous coronary intervention (PCI) in patients with unstable angina pectoris (UAP) are not well known in the era of new generation drug-eluting stents and medication. METHODS: In this single-centre retrospective study, a total of 2364 patients with UAP from January 2014 to June 2017 at Beijing Friendship Hospital were enrolled. The primary endpoint was a composite of major adverse cardiovascular events (MACEs), including all-cause death, cardiac death, nonfatal myocardial infarction and stroke at least 2 years after discharge. RESULTS: In this study, 1695 patients had low SYNTAX scores ([Formula: see text]), 432 patients had medium SYNTAX scores (23-32), 237 patients had high SYNTAX scores (≥ 33), 1018 received medical therapy, and 1346 patients underwent PCI. Long-term MACEs occurred in 95 patients during the 3.38 ± 0.99-year follow-up. Compared to the medical therapy group, the PCI group showed lower MACEs and cardiac death in patients with high SYNTAX scores (7.4% vs. 16.7%, P = 0.048; 3.7% vs. 14.6%, P = 0.004) but no reduction in patients with low and medium SYNTAX scores. Cox multivariate regression analysis showed that advanced age, diabetes mellitus, left ventricular ejection fraction (LVEF), hs-CRP and high SYNTAX score were independent predictors for MACEs in the medical therapy group (P < 0.05), whereas chronic kidney disease (CKD) and LVEF were predictors of MACEs in the PCI group. CONCLUSIONS: Compared to medical therapy, PCI could only significantly reduce long-term MACEs and cardiac death for patients with high SYNTAX scores but not for patients with low and medium SYNTAX scores. A high SYNTAX score could predict long-term MACEs for UAP patients in the medical therapy group but not in the PCI group.

Increased deformation of the left ventricle during exercise test measured by global longitudinal strain can rule out significant coronary artery disease in patients with suspected unstable angina pectoris.

BACKGROUND: Noninvasive identification of significant coronary artery disease (CAD) in patients with unstable angina pectoris (UAP) is challenging. Exercise stress testing has been used for years in patients with suspected CAD but has low diagnostic accuracy. The use of Global longitudinal strain (GLS) by speckle tracking echocardiography is a highly sensitive and reproducible parameter for detection of myocardial ischemia. Our aim was to study if identification of normal or ischemic myocardium by measurement of GLS immediately after an ordinary bicycle exercise stress testing in patients with suspected UAP could identify or rule out significant CAD. METHODS: Seventy-eight patients referred for coronary angiography from outpatient clinics and the emergency department with chest pain, inconclusive ECG and normal values of Troponin-T was included. All patients underwent echocardiographic examination at rest and immediately after maximum stress by exercise on a stationary bicycle. Significant CAD was defined by diameter stenosis > 90% by coronary angiography. In patients with coronary stenosis between 50-90%, fractional flow reserve (FFR) was measured and defined abnormal < .80. Analysis of echocardiographic data were performed blinded for angiographic data. Patients were discharged diagnosed with CAD (n = 34) or non-coronary chest pain (NCCP, n = 44). RESULTS: In patients with NCCP, GLS at rest was -21.1 ± 1.7% and -25.5 ± 2.6% at maximum stress (P < .01). In patients with CAD, GLS at rest was -16.8 ± 4.0% and remained unchanged at maximum stress (-16.6 ± 4.6%, P = .69). In patients with NCCP, LVEF was 56.1% ± 6.0 and increased to 61.8% 5.2, P < .01. In CAD patients, LVEF at rest was 54.7% ± 8.6 and increased to 58.2% ± 9.5 during stress, P = .16. In NCCP patients, Wall Motion Score index decreased .02 ± .07, P = .03 during stress and was without significant changes in patients with CAD. Area under the curve (AUC) for distinguishing CAD for was .97 (.95-1.00), .63 (.49-.76), and .71 (.59-.83) for GLS, LVEF, and WMSi, respectively. CONCLUSION: In patients with suspected UAP, increased deformation of the left ventricle measured by GLS immediately after exercise stress testing identified normal myocardium without CAD. Reduced LV contractile function by GLS without increase after exercise identified significant CAD.

Culprit Lesion Detection in Patients Presenting With Non-ST Elevation Acute Coronary Syndrome and Multivessel Disease.

BACKGROUND/PURPOSE: Identification of the culprit lesion in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) allows appropriate coronary revascularization but may be unclear in patients with multivessel coronary disease (MVD). Therefore, we investigated the rate of culprit lesion identification during coronary angiography in NSTE-ACS and multivessel disease. METHODS/MATERIALS: Consecutive patients presenting with NSTE-ACS and MVD, between January 2012 and December 2016 were evaluated. Coronary angiograms, intravascular imaging, and ECGs were analyzed for culprit lesion identification. Long-term clinical outcomes in terms of major adverse cardiac events (MACE) and mortality were reported in patients with or without culprit identification. RESULTS: A total of 1107 patients with NSTE-ACS and MVD were included in the analysis, 310 (28.0%) with unstable angina and 797 (72.0%) with non-ST elevation myocardial infarction. The culprit lesion was angiographically identified in 952 (86.0%) patients, while no clear culprit lesion was found in 155 (14.0%) patients. ECG analysis allowed to predict the location of the culprit vessel with low sensitivity (range 28.4%-36.7%) and high specificity (range 90.6%-96.5%). Higher lesion complexity was associated with inability to identify the culprit. Intravascular imaging was applied in 55 patients and helped to identify the culprit lesion in 53 patients (96.4%). There was no difference in all-cause mortality (21.4% vs. 25.8%, p = 0.24) and MACE (39.2% vs. 47.6%, p = 0.07) between the cohorts with or without culprit lesion identification by angiography. CONCLUSIONS: The culprit lesion appeared unclear by coronary angiography in >10% of patients with NSTE-ACS and MVD. Complementary invasive imaging substantially enhanced the diagnostic accuracy of culprit lesion detection.

Two-dimensional speckle tracking echocardiography derived post systolic shortening in patients with unstable angina and normal left ventricular systolic function.

OBJECTIVES: Post systolic shortening (PSS) had been shown to be sensitive in detecting ischemia on stress echocardiography. This work aims to study the diagnostic potential of resting PSS and post systolic index (PSI) in patients with suspected unstable angina (UA). METHODS: Total of 159 participants with suspected UA without any wall motion abnormalities were recruited. They all underwent speckle tracking echocardiography (STE) and coronary angiogram (CAG). Global longitudinal strain (GLS), presence or absence of pathological PSS, PSI17 and PSI12, PSI in left anterior descending, left circumflex and right coronary artery territories were assessed. Based on CAG those who had more than 70% stenosis were labelled to have obstructive CAD. RESULTS: Obstructive disease was noted in 54.7% patients. The prevalence of PSS (62.1% Vs 13.9%), mean PSI17 (5.4 Vs 3.3) and PSI12 (6.2 Vs 3.7) were significantly higher in those with CAD compared to patients without obstructive disease. Both PSS (Odds ratio-10.145; 95% CI, 4.577-22.489; p=0.001) and PSI17 (odds ratio-1.217;95 CI, 1.064-1.393; p=0.004) were predictors of CAD by multivariate regression analysis. PSS had a sensitivity of 62.1% and specificity of 86.1% with a positive predictive value of 84.4%. PSI17 (area under curve- 0.637; p=0.003) and PSI12 (AUC- 0.661; p=0.001) have moderate accuracy in identifying obstructive CAD. CONCLUSION: In patients presenting with suspected UA, STE derived PSS has reasonable sensitivity and good specificity in diagnosis of obstructive CAD. Patients identified to have PSS can be subjected to CAG without further stress testing because of its high positive predictive value.

Coronary catheterization via distal transradial access in patient with superficial radial artery: a case report.

BACKGROUND: The routine radial artery (RA) puncture may fail when anatomical variation of the RA is encountered. Superficial radial artery (SRA) is one of the anatomic variants of the RA, with the incidence of about 1 to 1.5%. Recently, distal transradial access (dTRA) has emerged as a novel approach for coronary catheterization (CC), but performing CC through dTRA in patient with SRA has never been reported. CASE PRESENTATION: A 57-year-old male was admitted to hospital due to intermittent chest pain for 4 days. He was diagnosed with unstable angina pectoris and planned to receive coronary angiography (CAG). Before the operation, the existence and course of SRA were confirmed by palpation and ultrasonography with color Doppler. We marked the puncture site under the guidance of ultrasonography and successfully performed CC through the dTRA during patient's hospitalization. CONCLUSIONS: As far as we know, this is the first report that presents a case of SRA and percutaneous coronary intervention (PCI) treatment in which was successfully performed through dTRA. It is safe and feasible to perform CC via dTRA in case of SRA, and dTRA seems to be the preferred access.

Flow reserve fraction: the optimal choice in lesion assessing and interventional guiding for patient with unstable angina pectoris and intermediate lesion wrapped with myocardial bridge: a case report.

BACKGROUND: It is difficult to choose correctly interventional strategy for coronary intermediate lesions combined with myocardial bridge. Endovascular imaging is advocated to guide treatment, but flow reserve fraction (FFR) is not recommended to guide the interventional treatment of myocardial bridge disease because of the inaccurate judgment misled by myocardial bridge. CASE PRESENTATION: In this study, we reported a case of a 56-year-old male patient with unstable angina pectoris (UAP). From his coronary angiography, we found diffuse stenosis near the midsection of the left anterior descending (LAD) branch and the presence of a severe myocardial bridge in the lesion area. We were sure that the LAD was culprit vessel and this lesion was culprit lesion. Both FFR and intravenous ultrasound (IVUS) were performed and the conclusions of them are different. Although stent implantation is not usually recommended in the myocardial bridge area. However, after careful examination, a stent was finally implanted under the precise guidance of FFR. And the patient recovered well up-to now. CONCLUSIONS: This case illustrates that FFR functional test was complimentary to intravascular imaging test for the coronary intermediate lesion, especially the lesion wrapped with myocardial bridges, both in assessing the lesion and in guiding treatment.

Long-Term Prognosis in Young Patients with Acute Coronary Syndrome Treated with Percutaneous Coronary Intervention.

BACKGROUND: Acute coronary syndrome (ACS) at a young age is uncommon. Limited data regarding the long-term follow-up and prognosis in this population are available. Our objectives were to evaluate the long-term clinical outcomes of patients presenting with ACS at a young age and to assess factors that predict long-term prognosis. METHODS: A retrospective analysis of consecutive young patients (male below 40 and female below 50 years old) that were admitted with ACS and underwent percutaneous coronary intervention (PCI) between the years 1997 and 2009. Demographics, clinical characteristics, and clinical outcomes including major cardiovascular (CV) events and mortality were analyzed. Multivariable cox proportional hazard model was performed to identify predictors of long-term prognosis. RESULTS: One-hundred sixty-five patients were included with a mean follow-up of 9.1±4.6 years. Most patients were men (88%), and mean age (years) was 36.8±4.2. During follow-up, 15 (9.1%) died, 98 (59.4%) patients had at least one major CV event, 22 (13.3%) patients had more than two CV events, and the mean number of recurrent CV events was 1.4±1.48 events per patient. In multivariate analysis, the strongest predictors of major CV events and/or mortality were coronary intervention without stent insertion (HR1.77; 95% CI 1.09-2.9), LAD artery involvement (HR 1.59; 95% CI 1.04-2.44) and hypertension (HR 1.6; 95% CI 1.0-2.6). CONCLUSION: Patients with ACS in young age are at high risk for major CV and/or mortality in long-term follow-up with a high rate of recurrent CV events. Close follow-up and risk factor management for secondary prevention have a major role, particularly in this population.

DNA and chromosomal damage in peripheral blood lymphocytes in patients with acute coronary syndrome undergoing a coronary angiography.

OBJECTIVE: The aim of the study was to evaluate the DNA and chromosomal damage in peripheral blood lymphocytes (PBLs) of patients with acute coronary syndrome (ACS) and to explore the effect of coronary angiographies in these patients. METHODS: The study included ACS patients who underwent a coronary angiography (CAG) and healthy controls. The ACS sample was divided into two groups: patients with unstable angina pectoris (UAP) and acute myocardial infarction (AMI). The frequency of DNA damage [expressed as genetic damage index (GDI)] was analyzed using the comet assay pre- and post-CAG. Chromosomal aberrations were measured as micronuclei (MNs) frequency using the cytokinesis-block MN (CBMN) assay. Additionally, detailed anamnestic data were taken from the each patient. RESULTS: Increased levels of DNA and chromosomal damage have been revealed in ACS patients compared to the healthy controls. GDI values were also significantly higher in AMI patients than in UAP patients. A highly significant increase of DNA damage was also observed in all patients post-CAG. There was significantly higher MN frequency and significantly lower nuclear division index (NDI) in AMI patients than in UAP patients' pre-CAG. After CAG, there was no significant difference in MN frequencies and NDI values between UAP and AMI patients. CONCLUSION: Correlated with disease severity, our results showed that AMI patients have higher levels of both DNA and chromosomal damage in PBLs compared to UAP patients. The increased level of genome instability was especially evident post-CAG compared to the observed damage pre-CAG.

Healed Erosion: The Role of Pre-interventional Optical Coherence Tomography in a Patient Clinically Suspected of Having Unstable Angina with Coronary Spasm.

A 46-year-old man complained of chest pain at rest for the past three months. His symptoms gradually exacerbated and were suspected of being due to unstable angina. A coronary angiogram revealed focal tight stenosis at the proximal left anterior descending coronary artery with gross spastic coronary findings. Optical coherence tomography (OCT) revealed layered low-intensity structures with microvessels and the accumulation of macrophages, which indicated progressive stenosis with multiple-layered organized thrombus caused by coronary erosion. We treated the stenosis using a drug-coated balloon instead of drug-eluting stents. There was no restenosis, and OCT revealed good plaque healing at follow-up. This case suggests that the pre-interventional OCT plaque morphology can have a positive impact on the revascularization strategy.