Usefulness of stress myocardial perfusion imaging and baseline clinical factors for predicting cardiovascular events in patients with prior coronary artery disease.

BACKGROUND: Stress myocardial perfusion imaging (MPI) is a well-established diagnostic and prognostic tool for coronary artery disease (CAD). However, fixed and/or reversible stress MPI defects vary considerably among patients with CAD. The usefulness of stress MPI and baseline clinical factors as independent predictors of cardiovascular events in patients with prior CAD were assessed. METHODS AND RESULTS: Stress MPI was performed in 354 patients with prior CAD. Their mean age was 71 years; the mean duration from first revascularization and/or myocardial infarction (MI) onset until stress MPI was 7.1 years; and the mean follow-up period was 34 months. Cardiovascular events were observed in 100 patients (28%), and were categorized as cardiac-related death, non-fatal MI, unstable angina, heart failure and late (>2 months from stress MPI) coronary revascularization. Multivariate Cox regression analysis revealed that peripheral arterial disease (hazard ratio [HR]=2.95; P<0.001), current smoking (HR=2.36; P=0.006), chronic kidney disease (HR=2.15; P<0.001), left ventricular ejection fraction (HR=0.98; P=0.017), and grade of myocardial ischemia assessed by stress MPI (HR=1.14; P=0.007) were independent and significant predictors of cardiovascular events. CONCLUSIONS: In patients with prior CAD, baseline clinical factors and grade of myocardial ischemia assessed by stress MPI results are significant predictors of cardiovascular events.

Coronary artery CT low-density plaque area and its ratio to the whole area of a non-calcified plaque at the culprit lesion in patients with unstable and stable coronary artery disease.

Intravascular ultrasound studies have shown that patients with unstable angina pectoris (UAP) more frequently had soft plaques in the culprit coronary arteries than patients with stable angina pectoris (SAP). We evaluated coronary plaque characteristics of culprit lesions in patients with UAP by 64-slice computed tomographic coronary angiography (64-slice CTCA). 64-slice CTCA (Aquilion 64, Toshiba Medical Systems, Otawara, Japan) was performed in 30 patients (UAP = 14, SAP = 16) before percutaneous coronary intervention (PCI). Coronary plaque area was measured by manual tracing for the difference between the area within the external elastic membrane and the area of the vessel lumen at the site of maximal luminal narrowing as observed on a cross-sectional 64-slice CTCA image where PCI was performed. Within this plaque area, CT low-density plaque area (< 50 Hounsfield units) was automatically calculated. There were no differences in stenotic rate and whole plaque area of the culprit lesion between patients with UAP and SAP. However, the CT low-density plaque area was significantly greater in patients with UAP than in those with SAP. A greater area of CT low-density plaque in the culprit lesion is associated with UAP rather than SAP. Measuring CT-low density plaque area on 64-slice CTCA images could be useful for understanding the clinical setting of UAP.

What Should We Do after the COVID-19 Vaccination? Vaccine-Associated Diseases and Precautionary Measures against Adverse Reactions.

COVID-19 vaccines have been used to counteract the global COVID-19 pandemic. While these are effective, adverse reactions have been reported, such as injection-site pain, muscle ache, fever, palpitation, and chest discomfort. The release of inflammatory cytokines, such as interleukin (IL)-6 and IL-1ß, is a potential mechanism for post-vaccine side-effects. Chest discomfort after the vaccination, including myocarditis and acute coronary syndrome, is a particularly serious adverse reaction. It is important to be familiar with the differential diagnoses of chest discomfort and organ-specific diseases associated with COVID-19 vaccines as the preparation for booster shots and vaccinations among children aged 5-11 years begins. High-intensity exercise, alcohol, tobacco smoking, and baths promote inflammatory cytokines, such as IL-6, which may exacerbate the adverse reactions after vaccination. Japanese data show that deaths during baths are the most common for several days after mRNA vaccination. Additionally, alcohol and tobacco smoking were identified as predictive factors of lower antibody titers after vaccination. In this review, we aimed to provide a few recommendations to prevent vaccine-associated disease.

A Possibility of Vasospastic Angina after mRNA COVID-19 Vaccination.

We report a case of vasospastic angina (VSA) following COVID-19 mRNA vaccination. Despite the widespread occurrence of myocarditis, there have been few reports of post-vaccinal VSA. A 41-year-old male patient was referred for chest pain at rest following mRNA vaccination; he had never experienced chest pain prior to vaccination. He was diagnosed by an acetylcholine (Ach) provocation test that showed multivessel vasospasm. After the initiation of treatment with a calcium channel blocker and nitrate, no further exacerbation of chest pain was observed. To our knowledge, this constitutes the first reported case of VSA proven by Ach provocation test after COVID-19 vaccination. The vaccination may increase coronary artery spasticity. VSA should be ruled out in post-vaccine new onset resting chest pain.

Detection of coronary artery disease by free-breathing, whole heart coronary magnetic resonance angiography: our initial experience.

Free-breathing, whole heart coronary magnetic resonance angiography (MRA) has gained great attention as a totally noninvasive diagnostic modality for the detection of coronary artery disease. We examined the accuracy of coronary MRA to identify the presence or absence of coronary artery stenosis in comparison with conventional coronary angiography. Free-breathing, whole heart coronary MRA was performed in 43 consecutive patients undergoing conventional coronary angiography. A total of 172 coronary arteries and 344 coronary artery segments were analyzed. In the coronary artery segment-based analysis, the sensitivity to detect coronary stenosis >/=50% was 82% and specificity was 100%. The accuracy, positive predictive value, and negative predictive value was 97%, 98%, and 96%, respectively. In the vessel-based analysis the sensitivity was 86%, specificity 99%, accuracy 95%, positive predictive value 98%, and negative predictive value 94%. In the patient-based analysis, the sensitivity to detect coronary stenosis <50% was 97% and the specificity to define luminal narrowing <50% was 90%. The accuracy, positive predictive value, and negative predictive value was 95%, 97%, and 90%, respectively. Free-breathing, whole heart coronary MRA yields excellent diagnostic accuracy to detect significant coronary artery disease and has the potential to become the routine diagnostic modality for patients with suspected coronary artery disease.

Right ventricular involvement in a patient with isolated noncompaction of the ventricular myocardium.

Isolated noncompaction of the ventricular myocardium (INVM) is an unclassified cardiomyopathy and is thought to be due to arrest of myocardial morphogenesis. Although right ventricular involvement is not uncommon, the correct diagnosis is often difficult by echocardiography. In this report, we describe a patient with INVM in whom magnetic resonance imaging was useful to detect right ventricular morphological and functional abnormalities.

Multidetector row computed tomographic findings in a patient with anomalous origin of the right coronary artery from the left sinus of Valsalva.

Anomalous origin of the right coronary artery (RCA) is a rare congenital anomaly, which may cause myocardial ischemia and sudden death. However, the causes of myocardial ischemia remain uncertain. Multidetector row computed tomography (MDCT) was performed in a 22-year-old woman who had exercise-induced myocardial ischemia. MDCT revealed a small orifice of the RCA in the left sinus of Valsalva, separate from the left main coronary artery, an acute-angled takeoff from the aorta, an intramural course of the proximal portion within the aortic wall, and a course between the great vessels. Three-dimensional virtual angioscopy also depicted a small orifice.

Noncompaction of the ventricular myocardium mimicking ischemic cardiomyopathy.

A 68-year-old woman was admitted to our hospital because of left ventricular failure. Myocardial perfusion single-photon emission computed tomography demonstrated a non-reversible perfusion defect in the anterolateral left ventricular segments and reduced ejection fraction, findings consisted with ischemic cardiomyopathy accompanied by lateral wall infarction. Coronary angiogram was normal, but the left ventriculogram showed prominent trabeculations in the apical and anterolateral segments. The left ventricular ejection fraction was 28%. Cine magnetic resonance imaging demonstrated prominent trabeculations and deep intertrabecular recesses, findings consistent with noncompaction of the ventricular myocardium. Myocardial hypoperfusion or necrosis in the noncompacted myocardium may be the cause of myocardial damage and possibly the basis of left ventricular failure.

Prediction of cardiovascular events in pre-dialysis chronic kidney disease patients with normal SPECT myocardial perfusion imaging.

PURPOSE: Patients with normal stress myocardial perfusion imaging (MPI) results generally have an excellent prognosis with <1% cardiovascular events/year. Chronic kidney disease (CKD) is an established risk factor for cardiovascular events. However, the estimated glomerular filtration rate (eGFR) varies considerably among patients with CKD. We evaluated the prognostic value of eGFR for patients with CKD who did not undergo hemodialysis and had no evidence of coronary artery disease (CAD). METHODS AND SUBJECTS: Patients with CKD (n=108; 58 males; mean age: 74 years) with no CAD [no previous CAD and normal stress MPI results; summed stress score (SSS) <4] and with no history of hemodialysis were followed-up (mean duration: 24 months). CKD was defined by eGFR of <60 ml/min/1.73 m(2) and/or persistent proteinuria. Cardiovascular events included cardiac death, non-fatal myocardial infarction, and unstable angina. RESULTS: Cardiovascular events were observed in 8 patients with CKD (7%). The following were determined as significant predictors of these events: age (hazard ratio=1.14; p=0.019), hemoglobin levels (hazard ratio=0.69; p=0.021), eGFR (hazard ratio=0.94; p=0.008), SSS (hazard ratio=2.31; p=0.012), and summed difference score (hazard ratio=2.33; p=0.014). CONCLUSIONS: Patients with CKD and with no previous CAD and normal stress MPI results (SSS<4) may not exhibit an excellent cardiovascular prognosis. Further, a lower eGFR and stress MPI results may be the predictors of cardiovascular events. Thus, patients with a lower eGFR and/or normal stress MPI results (SSS<4) may require continuous follow-up.

Predictors of cardiovascular events in hemodialysis patients after stress myocardial perfusion imaging.

Cardiovascular prognosis in patients under normal stress myocardial perfusion images (MPI) is generally excellent. However, this is not true for patients with chronic kidney disease (CKD) treated by hemodialysis. This study evaluated prognostic factors of adverse cardiovascular events in hemodialysis patients in whom stress MPI was performed. Pharmacological stress MPI was performed in 88 hemodialysis patients, and we retrospectively followed-up for 26 months. Cardiovascular events included cardiac death, nonfatal myocardial infarction, and unstable angina. Cardiovascular events occurred in 16 patients (18%). Univariate Cox regression analysis revealed that peripheral artery disease (PAD) and parameters of stress MPI were significant predictors of cardiovascular events. Multivariate Cox regression analysis revealed that only PAD (hazard ratio=6.54; P=0.002), and abnormal stress MPI (hazard ratio=8.26; P=0.008) were independent and significant predictors of cardiovascular events. Kaplan-Meier analysis showed better prognosis in patients with normal stress MPI than in patients with abnormal stress MPI (P<0.001, log-rank test). However, in patients with normal stress MPI, cardiovascular events occurred in 10 of the 76 patients (13%). Among patients with normal stress MPI, Kaplan-Meier analysis showed that patients with no PAD had better prognosis than patients with PAD (P=0.001, log-rank test). In hemodialysis patients, both PAD and stress MPI were powerful cardiovascular predictors. Normal stress MPI alone cannot guarantee good prognosis in terms of cardiovascular events. Consideration of PAD may improve the predictive value of stress MPI in some patients.

Lower ratio of high-molecular-weight adiponectin level to total may be associated with coronary high-risk plaque.

BACKGROUND: Although high-molecular-weight (HMW) adiponectin is believed to protect against atherosclerosis, the association between HMW adiponectin and the composition of coronary plaques is unknown. We evaluated whether the HMW to total adiponectin ratio was associated with the presence of coronary plaque and its composition using multi-slice computed tomography coronary angiography (MSCTCA). METHODS: Serum total and HMW adiponectin levels were measured in 53 consecutive patients (age, 71) with >50% coronary artery stenosis detected by MSCTCA. A low-attenuation coronary plaque was defined as a plaque with a mean CT density <50 Hounsfield units. Multivariate logistic regression analyses were performed to evaluate the predictors of the presence of low-attenuation coronary plaques, which is thought to be high risk, on CT. RESULTS: Decreased serum levels of total as well as HMW adiponectin were significantly associated with the presence of at least one calcified or non-calcified coronary artery plaque (total adiponectin level: odds ratio 0.76, 95% CI 0.58-0.99, P = 0.048; HMW adiponectin level: odds ratio 0.65, 95% CI 0.42-0.99, P = 0.047). A low ratio of HMW to total adiponectin was significantly associated with the presence of low-attenuation coronary plaques (4.55, 1.94-21.90, P = 0.049). However, neither the total adiponectin nor the HMW adiponectin level was associated with the presence of low-attenuation coronary plaques. CONCLUSION: Lower total or HMW adiponectin levels are associated with the presence of calcified and non-calcified coronary plaques, whereas a lower ratio of HMW to total adiponectin associated with the presence of low-attenuation coronary plaques (thought to be high risk). Measurement of total and HMW adiponectin levels and the HMW to total adiponectin ratio may be useful for risk stratification of coronary artery plaques.

The predictive value of chronic kidney disease for assessing cardiovascular events under consideration of pretest probability for coronary artery disease in patients who underwent stress myocardial perfusion imaging.

Pretest probability of coronary artery disease (CAD) facilitates diagnosis and risk stratification of CAD. Stress myocardial perfusion imaging (MPI) and chronic kidney disease (CKD) are established major predictors of cardiovascular events. However, the role of CKD to assess pretest probability of CAD has been unclear. This study evaluates the role of CKD to assess the predictive value of cardiovascular events under consideration of pretest probability in patients who underwent stress MPI. Patients with no history of CAD underwent stress MPI (n = 310; male = 166; age = 70; CKD = 111; low/intermediate/high pretest probability = 17/194/99) and were followed for 24 months. Cardiovascular events included cardiac death and nonfatal acute coronary syndrome. Cardiovascular events occurred in 15 of the 310 patients (4.8 %), but not in those with low pretest probability which included 2 CKD patients. In patients with intermediate to high pretest probability (n = 293), multivariate Cox regression analysis identified only CKD [hazard ratio (HR) = 4.88; P = 0.022) and summed stress score of stress MPI (HR = 1.50; P < 0.001) as independent and significant predictors of cardiovascular events. Cardiovascular events were not observed in patients with low pretest probability. In patients with intermediate to high pretest probability, CKD and stress MPI are independent predictors of cardiovascular events considering the pretest probability of CAD in patients with no history of CAD. In assessing pretest probability of CAD, CKD might be an important factor for assessing future cardiovascular prognosis.

Impact of chronic kidney disease and stress myocardial perfusion imaging as a predictor of cardiovascular events.

BACKGROUND: Stress myocardial perfusion imaging (MPI) is an established means of predicting cardiovascular events and is suitable in chronic kidney disease (CKD) patients. We aimed to evaluate the prognostic value of CKD parameters and an abnormal stress MPI for cardiovascular events. METHODS: A total of 495 patients with suspected coronary artery disease (CAD) or history of CAD including 130 CKD patients not undergoing hemodialysis, underwent stress MPI (313 males, mean age 70 years) and were followed up for 14 months (mean period). CKD was defined as an estimated GFR of <60 ml/min/1.73 m(2) and/or persistent proteinuria. Cardiovascular events were defined as sudden cardiac death, acute coronary syndrome and congestive heart failure requiring hospitalization. RESULTS: Cardiovascular events occurred in 41 (8.3%) patients. Multivariate Cox regression analysis indicated that CKD [hazard ratio (HR) = 3.76, p < 0.001] and a stress MPI summed difference score (SDS) of ≥2 (HR = 3.78, p < 0.001) were independent predictors of cardiovascular events; CKD plus abnormal stress MPI was also a strong predictor of cardiovascular events (non-CKD and SDS <2 vs. CKD and SDS ≥2, HR = 15.9, p < 0.001). CONCLUSION: Both CKD and myocardial ischemia detected by stress MPI are independent predictors for cardiovascular events. Coexistence of CKD and myocardial ischemia detected by stress MPI is more useful for short-term risk stratification of cardiovascular events.

Correlation of chronic kidney disease, diabetes and peripheral artery disease with cardiovascular events in patients using stress myocardial perfusion imaging.

OBJECTIVE: Normal stress myocardial perfusion imaging (MPI) studies generally suggest an excellent prognosis for cardiovascular events. Chronic kidney disease (CKD), diabetes and peripheral artery disease (PAD) have been established as the risk factors for cardiovascular events. However, whether these risk factors significantly predict cardiovascular events in patients with normal stress MPI is unclear. The purpose of this study was to evaluate the prognostic value of these risk factors in patients with normal stress MPI. METHODS: Patients with normal stress MPI (n = 372, male = 215 and female = 157, age = 69 years, CKD without hemodialysis = 95, diabetes = 99, PAD = 19, previous coronary artery disease = 116) were followed up for 14 months. Normal stress MPI was defined as a summed stress score of <4 and a summed difference score of <2. CKD was defined by an estimated glomerular filtration rate of <60 ml/min/1.73 m(2) and/or persistent proteinuria. Cardiovascular events included cardiac death, non-fatal myocardial infarction and congestive heart failure requiring hospitalization. RESULTS: Cardiovascular events occurred in 20 of 372 patients (5.4%). In univariate Cox regression analysis, PAD, diabetes, diabetic retinopathy, insulin use, anemia, hypoalbuminemia, CKD, left ventricular ejection fraction and pharmacological stress tests were significant predictors of cardiovascular events. In multivariate Cox regression analysis, PAD, diabetes and CKD were independent and significant predictors for cardiovascular events, and their number was the strongest predictor for cardiovascular events (hazard ratio = 21.7, P < 0.001). CONCLUSIONS: PAD, diabetes and CKD are coexisting, independent and significant risk factors for cardiovascular events, CKD being the strongest predictor. The number of coexisting risk factors is important in predicting cardiovascular events in patients with normal stress MPI.

MDCT of the anomalous origin of the right coronary artery from the left sinus of Valsalva associated with bicuspid aortic valve.

Anomalous origin of the right coronary artery is a relatively rare coronary artery anomaly which is known to cause myocardial ischemia and sudden death. Association of anomalous origin of the right coronary artery with congenital bicuspid aortic valve is even rarer with only a few cases being reported previously. We describe, for the first time, MDCT findings of anomalous origin of the right coronary artery associated with congenital bicuspid aortic valve.

The impact of chronic kidney disease as a predictor of major cardiac events in patients with no evidence of coronary artery disease.

BACKGROUND: Normal stress myocardial perfusion images (MPI) generally show good prognosis for cardiovascular events. However, chronic kidney disease (CKD) is one of the important risk factors for coronary artery disease (CAD), and the interpretation of normal stress MPI has not been well established in CKD patients with no evidence of CAD. The purpose of this study was to evaluate the long-term prognostic value of stress MPI in CKD patients with no evidence of myocardial ischemia or infarction. METHODS: Patients who had no history but were suspected of CAD and had normal stress MPI (n=307, male=208, age=67 years, CKD/non-CKD=46/261) were followed-up for 4.5 years. CKD was defined as a glomerular filtration ratio of <60 ml/min/1.73 m(2) and/or persistent proteinuria. Cardiac death, non-fatal myocardial infarction, and unstable angina requiring hospitalization were defined as major cardiac events. RESULTS: Major cardiac events were observed in 3 of 261 (1.1%) non-CKD patients and 6 of 46 (13%) CKD patients (p<0.001, with log-rank test). CKD was an independent risk factor for major cardiac events (hazard ratio=13.1, p<0.001, multivariate Cox regression analysis). CONCLUSIONS: Normal stress MPI does not always promise a good prognosis for major cardiac events. Even in patients with no evidence of CAD from stress MPI, CKD can be an independent and significant risk factor for major cardiac events.

Acute anterior myocardial infarction superimposing double left anterior descending artery: depiction at whole-heart coronary magnetic resonance angiography.

Double left anterior descending artery arising from the left and right coronary arteries is an extremely rare congenital coronary anomaly. We describe a patient with anterior myocardial infarction, in whom whole-heart coronary magnetic resonance angiography detected double left anterior descending artery.

Myocardial necrosis in both left and right ventricles detected by delayed-enhanced magnetic resonance imaging in a patient with isolated noncompaction of the ventricular myocardium.

A 58-year-old man presented with left ventricular failure. Coronary angiography revealed normal coronary arteries and endomyocardial biopsy from the right ventricular apex was normal. Echocardiogram showed marked trabeculation and deep intertrabecular recesses most prominent in the left ventricular apex, anterior and the lateral wall. Cine magnetic resonance imaging showed double-layered appearance on long-axis, 4-chamber and short-axis views. These findings were consistent with isolated noncompaction of the ventricular myocardium (INVM). Gadolinium-diethylenetriomine pentaacetic acid-enhanced imaging revealed delayed enhancement in the both left and right ventricular myocardium.

Whole-heart magnetic resonance imaging of isolated subpulmonary stenosis accompanied by hypertrophic cardiomyopathy.

Isolated subvalvular pulmonary stenosis (ISPS) is a rare condition, and it is often accompanied by hypertrophic cardiomyopathy. However, diagnosis of ISPS is obscure because of difficulty in comprehension of three-dimensional cardiac anatomy. Whole-heart magnetic resonance imaging (MRI) is a new, totally non-invasive technique which allows not only depiction of the coronary artery system, but also three-dimensional comprehension of the cardiac structure. We describe a patient with ISPS associated with hypertrophic cardiomyopathy, in whom whole-heart MRI was useful to detect and evaluate the cause of ISPS.