Critical Assessment of the Management of Unstable Angina in a Specialized Cardiology Emergency Room. / Avaliação Crítica do Manejo da Angina Instável em Pronto-Socorro Terciário de Cardiologia.

BACKGROUND: The management of unstable angina (UA) presents a challenge due to its subjective diagnosis and limited representation in randomized clinical trials that inform current practices. OBJECTIVES: This study aims to identify key factors associated with the indication for invasive versus non-invasive stratification in this population and to evaluate factors associated with stratification test results. METHODS: This retrospective cohort study included patients hospitalized with UA over a consecutive 20-month period. To assess factors associated with stratification strategies, patients were divided into invasive stratification (coronary angiography) and non-invasive stratification (other methods) groups. For the analysis of factors related to changes in stratification tests, patients were categorized into groups with or without obstructive coronary artery disease (CAD) or ischemia, as per the results of the requested tests. Comparisons between groups and multiple logistic regression analyses were performed, with statistical significance set at a 5% level. RESULTS: A total of 729 patients were included, with a median age of 63 years and a predominance of males (64.6%). Factors associated with invasive stratification included smoking (p = 0.001); type of chest pain (p < 0.001); "crescendo" pain (p = 0.006); TIMI score (p = 0.006); HEART score (p = 0.011). In multivariate analysis, current smokers (OR 2.23, 95% CI 1.13-4.8), former smokers (OR 2.19, 95% CI 1.39-3.53), and type A chest pain (OR 3.39, 95% CI 1.93-6.66) were independently associated. Factors associated with obstructive CAD or ischemia included length of hospital stay (p < 0.001); male gender (p = 0.032); effort-induced pain (p = 0.037); Diamond-Forrester score (p = 0.026); TIMI score (p = 0.001). In multivariate analysis, only chest pain (type B chest pain: OR 0.6, 95% CI 0.38-0.93, p = 0.026) and previous CAD (OR 1.42, 95% CI 1.01-2.0, p = 0.048) were independently associated. CONCLUSION: The type of chest pain plays a crucial role not only in the diagnosis of UA but also in determining the appropriate treatment. Our results highlight the importance of incorporating pain characteristics into prognostic scores endorsed by guidelines to optimize UA management.

FUNDAMENTO: O manejo da angina instável (AI) é um desafio devido ao seu diagnóstico subjetivo e à sua escassa representação em ensaios clínicos randomizados que determinem as práticas atuais. OBJETIVOS: O objetivo deste estudo é identificar os principais fatores associados à indicação de estratificação invasiva ou não nessa população e avaliar os fatores associados às alterações nos exames de estratificação. MÉTODOS: Coorte retrospectiva de pacientes internados por AI, em um período de 20 meses consecutivos. Para avaliar os fatores associados à estratégia de estratificação, os pacientes foram divididos em estratificação invasiva (cinecoronariografia) e não invasiva (demais métodos). Para análise de fatores relacionados às alterações nos exames de estratificação, os pacientes foram divididos em grupos com ou sem doença arterial coronariana (DAC) obstrutiva ou isquemia, conforme resultados dos exames solicitados. Foram realizadas comparações entre grupos e análise de regressão logística múltipla, com significância estatística definida em um nível de 5%. RESULTADOS: 729 pacientes foram incluídos, com mediana de idade de 63 anos e predomínio do sexo masculino (64,6%). Estiveram associados à estratificação invasiva: tabagismo (p = 0,001); tipo de dor torácica (p < 0,001); dor "em crescendo" (p = 0,006); escore TIMI (p = 0,006); escore HEART (p = 0,011). Na análise multivariada, tabagistas (OR 2,23, IC 95% 1,13-4,8), ex-tabagistas (OR 2,19, IC 1,39-3,53) e dor torácica tipo A (OR 3,39, IC 95% 1,93-6,66) estiveram associados de forma independente. Estiveram associados à DAC obstrutiva ou isquemia: tempo de internação hospitalar (p < 0,001); sexo masculino (p = 0,032); dor desencadeada por esforço (p = 0,037); Diamond-Forrester (p = 0,026); escore TIMI (p = 0,001). Na análise multivariada, apenas dor torácica (dor torácica tipo B: OR 0,6, IC 95% 0,38-0,93, p = 0,026) e DAC prévia (OR 1,42, IC 95% 1,01-2,0, p = 0,048) estiveram associadas de maneira independente. CONCLUSÕES: O tipo de dor torácica desempenha um papel crucial não apenas no diagnóstico da AI, mas também na definição do tratamento adequado. Nossos resultados destacam a importância de incorporar características da dor aos escores prognósticos endossados pelas diretrizes, para otimização do manejo da AI.

Elevated Serum Total Bilirubin Might Indicate Poor Coronary Conditions for Unstable Angina Pectoris Patients beyond as a Cardiovascular Protector.

Backgrounds: Serum total bilirubin (STB) is recently more regarded as an antioxidant with vascular protective effects. However, we noticed that elevated STB appeared in unstable angina pectoris (UAP) patients with diffused coronary lesions. We aimed to explore STB's roles in UAP patients, which have not been reported by articles. Methods and Results: 1120 UAP patients were retrospectively screened, and 296 patients were finally enrolled. They were grouped by Canadian Cardiovascular Society (CCS) angina grades. The synergy between PCI with TAXUS stent and cardiac surgery score (SYNTAX score) and corrected thrombolysis in myocardial infarction flow count (CTFC) were adopted to profile coronary features. The results showed that STB, mean platelet volume (MPV), hs-CRP, fasting blood glucose (FBG), red blood cell width (RDW), and CTFC elevated significantly in the CCS high-risk group. STB (B = 0.59, 95% CI: 0.39-0.74, P < 0.01) and MPV (B = 0.86, 95% CI: 0.42-1.31, P < 0.01) could indicate SYNTAX score changes for these patients. STB (≥21.7 µmol/L) could even indicate a coronary slow flow condition (AUC: 0.88, 95% CI: 0.84-0.93, P < 0.01). Moreover, UAP patients with elevated STB had a lower event-free survival rate by the Kaplan-Meier curve. STB ≥21.7 µmol/L could reflect a poor coronary flow status and indicate 1-year poor outcomes for these patients (HR: 2.01, 95% CI: 1.06-3.84, P < 0.01). Conclusion: Elevated STB in UAP patients has a close relationship with changes in SYNTAX score. STB (over 21.7 µmol/L) could even indicate a coronary slow flow condition and poor outcomes for the UAP patients.

[The role of growth differentiation factor-15 in assessing the prognosis of patients after uncomplicated myocardial infarction].

Aim    To study the role of growth differentiation factor 15 (GDF-15) in the long-term prognosis for patients after uncomplicated myocardial infarction (MI).Material and methods    This study included 118 MI patients aged <70 years with and without ST-segment elevation on electrocardiogram (ECG). All patients underwent an examination that included ECG, echocardiography, Holter ECG monitoring, routine laboratory tests, and tests for plasma N-terminal pro-brain natriuretic peptide (NT-proBNT) and GDF-15. GDF-15 was measured by ELISA. The dynamics of patients was evaluated by interviews at 1, 3, 6, and 12 months. The endpoints were cardiovascular death and hospitalization for recurrent MI and/or unstable angina. Results    Median concentration of GDF-15 in MI patients was 2.07 (1.55; 2.73) ng/ml. No significant dependence was found between GDF-15 concentration and age and gender, MI localization, smoking, body weight index, total cholesterol, and low-density lipoprotein cholesterol. During 12-month follow-up, 22.8 % of patients were hospitalized for unstable angina or recurrent MI. In 89.6 % of all cases of recurrent events, GDF-15 was ≥2.07 ng/ml. For patients with GDF-15 in the upper quartile, the time dependence of recurrent MI was logarithmic. High concentrations of NT-proBNP in MI patients were also associated with increased risk of cardiovascular death and recurrent cardiovascular events [RR, 3.3 (95 % CI, 1.87-5.96), р=0.046].Conclusion    A combination of GDF-15 and NT-proBNP at high concentrations significantly reflects an adverse prognosis for patients with uncomplicated MI within 12 months [RR, 5.4 (95 % CI, 3.4-8.5), р=0.004].

Effects of Serum LDL-C, CysC, and D-D in Patients with Coronary Atherosclerotic Heart Disease.

Objective: To investigate the effects of low-density lipoprotein cholesterol (LDL-C) and serum cystatin C (CysC) combined with D-dimer (D-D) on patients with coronary atherosclerotic heart disease (CHD). Methods: 90 patients with CHD who were admitted to our hospital and diagnosed by coronary angiography (CAG) from February 2020 to June 2021 were selected as the study subjects. 90 patients were grouped according to different types and branches of coronary lesions, and 30 patients with outpatient health check-ups at the same period were selected as the control group, and the differences in serum LDL-C, CysC, and D-D levels between the groups were compared. The logistic regression model was built to explore risk factors affecting the occurrence of CHD. Also, receiver operating characteristic (ROC) curves were drawn to analyze the diagnostic value of LDL-C, CysC, and D-D in CHD. Results: In the comparison of LDL-C, CysC, and D-D levels, CHD group > control group (P < 0.05); stable angina (SAP) group > unstable angina (UAP) group > acute myocardial infarction (AMI) group (P < 0.05); three-branch group > two-branch group > single-branch group (P < 0.05). The logistic regression model showed that high expression levels of LDL-C, CysC, and D-D, male gender, and combined hypertension were risk factors for CHD. The area under the curve (AUC) of the combination of LDL-C, CysC, and D-D was 0.868, and the sensitivity and specificity were 88.89% and 73.33%, respectively, which are higher than those in single diagnosis (P < 0.05). Conclusions: LDL-C, CysC, and D-D are highly expressed in CHD samples, and the combination of the three is beneficial to enhance the diagnostic accuracy of clinical CHD.

Predictors of long-term symptom burden and quality of life in patients hospitalised with chest pain: a prospective observational study.

OBJECTIVE: To describe the magnitude and predictors of symptom burden (SB) and quality of life (QoL) 3 months after hospital admission for acute chest pain. DESIGN: Prospective observational study. SETTING: Single centre, outpatient follow-up. PARTICIPANTS: 1506 patients. OUTCOMES: Scores reported for general health (RAND-12), angina-related health (Seattle Angina Questionnaire 7 (SAQ-7)) and dyspnoea (Rose Dyspnea Scale) 3 months after hospital admission for chest pain. METHODS: A total of 1506 patients received questionnaires assessing general health (RAND-12), angina-related health (SAQ-7) and dyspnoea (Rose Dyspnea Scale) 3 months after discharge. Univariable and multivariable regression models identified predictors of SB and QoL scores. A mediator analysis identified factors mediating the effect of an unstable angina pectoris (UAP) diagnosis. RESULTS: 774 (52%) responded. Discharge diagnoses were non-ST elevation myocardial infarction (NSTEMI) (14.2%), UAP (17.1%), non-coronary cardiac disease (6.6%), non-cardiac disease (6.3%) and non-cardiac chest pain (NCCP) (55.6%). NSTEMI had the most favourable, and UAP patients the least favourable SAQ-7 scores (median SAQ7-summary; 88 vs 75, p<0.001). NCCP patients reported persisting chest pain in 50% and dyspnoea in 33% of cases. After adjusting for confounders, revascularisation predicted better QoL scores, while UAP, current smoking and hypertension predicted worse outcome. NSTEMI and UAP patients who were revascularised reported higher scores (p<0.05) in SAQ-7-QL, SAQ7-PL, SAQ7-summary (NSTEMI) and all SAQ-7 domains (UAP). Revascularisation altered the unstandardised beta value (>±10%) of an UAP diagnosis for all SAQ-7 and RAND-12 outcomes. CONCLUSIONS: Patients with NSTEMI reported the most favourable outcome 3 months after hospitalisation for chest pain. Patients with other diseases, in particular UAP patients, reported lower scores. Revascularised NSTEMI and UAP patients reported higher QoL scores compared with patients receiving conservative treatment. Revascularisation mediated all outcomes in UAP patients. TRIAL REGISTRATION NUMBER: NCT02620202.

Diagnostic efficacy of serum ST2 in patients with ASC.

BACKGROUND: Soluble suppression of tumorigenicity 2 (ST2) is closely related to the development of cardiovascular disease, but the level of acute coronary syndrome (ACS) and the relationship between ST2 and ACS are unclear. PATIENTS AND METHODS: Patients with the acute coronary syndrome were divided into the unstable angina pectoris (USAP) group (n = 65) and non-ST-segment elevation myocardial infarction (NSTEMI) group (n = 58), and the healthy population, without chest pain and with normal coronary CT, was included as a control group (n = 55). Laboratory index levels were collected from each participant. The baseline information was reviewed and analyzed. The binary logistic regression was used to explore the relation of ST2 levels with the occurrence of ACS and NSTEMI, and the diagnostic performance of ST2 for diagnosing ACS or NSTEMI was evaluated using a receiver-operating characteristic (ROC) curve. RESULTS: The level of ST2 was found significantly higher in NSTEMI than in USAP and was higher in USAP than in control (p < 0.01). ST2 levels were positively correlated with ALT, AST, and BNP in the control group, were negatively correlated with HGB and TG in the USAP group, and were positively correlated with WBC, GLU, BNP, and Gensini scores in the NSTEMI group. Multivariate analysis revealed that the occurrence of ACS was associated with ST2, BNP, GLU, TC, BUN, WBC, and PLT, and the occurrence of NSTEMI was associated with AST, WBC, LDL-C, and ST2. Meanwhile, ST2 levels achieved good performance for ACS and NSTEMI diagnostician. CONCLUSION: ST2 could be used as an auxiliary diagnostic indicator for the occurrence of ACS and NSTEMI.

A pathway phenotype linking metabolic, immune, oxidative, and opioid pathways with comorbid depression, atherosclerosis, and unstable angina.

BACKGROUND: There is strong comorbidity between atherosclerosis (ATS) and depression which is attributed to increased atherogenicity, insulin resistance (IR), and immune and oxidative stress. AIM OF THE STUDY: To examine the role of the above pathways and mu-opioid receptor (MOR), ß-endorphin levels, zinc, copper, vitamin D3, calcium, and magnesium in depression due to ATS/unstable angina (UA). METHODS: Biomarkers were assayed in 58 controls and 120 ATS patients divided into those with moderate and severe depression according to the Beck Depression Inventory-II (BDI-II) scores >19 and >29, respectively. RESULTS: Neural network and logistic regression models showed that severe depression due to ATS/UA was best predicted by interleukin-6 (IL-6), UA, MOR, zinc, ß-endorphin, calcium and magnesium, and that moderate depression was associated with IL-6, zinc, MOR, ß-endorphin, UA, atherogenicity, IR, and calcium. Neural networks yielded a significant discrimination of severe and moderate depression with an area under the receiver operating curves of 0.831 and 0.931, respectively. Using Partial Least Squares path analysis, we found that 66.2% of the variance in a latent vector extracted from ATS/UA clinical features, and the BDI-II scores, atherogenicity, and IR could be explained by the regression on IL-6, IL-10, zinc, copper, calcium, MOR, and age. The BDI-II scores increased from controls to ATS to UA class III to UA class IV. CONCLUSIONS: Immune activation, the endogenous opioid system, antioxidants, trace elements, and macrominerals modulate a common core shared by increased depressive symptoms, ATS, UA, atherogenicity, and IR.

HEMOSTASIS DISORDERS IN CORONARY ARTERY DISEASE: A PROSPECTIVE COMPARATIVE STUDY OF 130 PATIENTS.

The laboratory detection of factors that participate in coagulation mechanisms in patients with coronary heart disease may lead to important findings regarding the contribution of endothelial function to atherosclerotic lesions of coronary arteries. The main purpose of this study was to investigate the role of high-sensitivity C-reactive protein (hs-CRP), von Willebrand factor (vWF) activity, thrombomodulin (TM), ADAMTS13 activity and myeloperoxidase (MPO) in patients undergoing coronary angiography due to non-ST-elevation myocardial infarction (NSTEMI), unstable angina (UA) and stable angina pectoris with positive stress testing-induced myocardial ischemia (controls). Furthermore, the measured biomarkers were examined among patients with classical cardiovascular risk factors. 50 NSTEMI patients, 50 UA patients and 30 controls referred to coronary angiography were included in the study. The blood samples were collected before the catheter procedure. MPO, TM and ADAMTS13 activity were measured by enzyme-linked immunosorbent assay (ELISA), while vWF activity was calculated with INNOVANCE vWF Ac. When the laboratory results were compared between the three study groups, hs-CRP was found to be higher in NSTEMI patients compared to UA patients (p=0.0015) and controls (p<0.0001). ADAMTS13 activity was higher in NSTEMI (p=0.0035) and UA patients (p=0.0102) compared to controls and TM was lower in NSTEMI patients compared to UA patients (p=0.0307) and controls (p=0.0002). Moreover, MPO was higher in UA patients compared to the control group (p=0.0227). Finally, each of the aforementioned biomarkers was compared in the presence of the following cardiovascular risk factors: smoking, diabetes mellitus, arterial hypertension, dyslipidemia, chronic kidney disease (CKD) and peripheral artery disease (PAD). The results of this study add more data to the current medical literature concerning the role of coagulation disorders, endothelial damage and immunothrombosis in patients with coronary artery disease and their correlation with traditional risk factors for cardiovascular disease.

Stage 1 hypertension, sex, and acute coronary syndromes during midlife: the Hordaland Health Study.

AIMS: Hypertension has been suggested as a stronger risk factor for acute coronary syndromes (ACS) in women than men. Whether this also applies to stage 1 hypertension [blood pressure (BP) 130-139/80-89 mmHg] is not known. METHODS AND RESULTS: We tested associations of stage 1 hypertension with ACS in 12 329 participants in the Hordaland Health Study (mean baseline age 41 years, 52% women). Participants were grouped by baseline BP category: Normotension (BP < 130/80 mmHg), stage 1 and stage 2 hypertension (BP ≥140/90 mmHg). ACS was defined as hospitalization or death due to myocardial infarction or unstable angina pectoris during 16 years of follow-up. At baseline, a lower proportion of women than men had stage 1 and 2 hypertension, respectively (25 vs. 35% and 14 vs. 31%, P < 0.001). During follow-up, 1.4% of women and 5.7% of men experienced incident ACS (P < 0.001). Adjusted for diabetes, smoking, body mass index, cholesterol, and physical activity, stage 1 hypertension was associated with higher risk of ACS in women [hazard ratio (HR) 2.18, 95% confidence interval (CI) 1.32-3.60], while the association was non-significant in men (HR 1.30, 95% CI 0.98-1.71). After additional adjustment for systolic and diastolic BP, respectively, stage 1 diastolic hypertension was associated with ACS in women (HR 2.79 [95% CI 1.62-4.82]), but not in men (HR 1.24 [95% CI 0.95-1.62]), while stage 1 systolic hypertension was not associated with ACS in either sex. CONCLUSION: Among subjects in their early 40s, stage 1 hypertension was a stronger risk factor for ACS during midlife in women than in men.

The Relationship between Serum and Gene Expression Levels of RANK, RANKL and Osteoprotegerin Inflammatory Pathway with Unstable Angina: A Case-control Study.

 Osteoprotegerin (OPG), receptor activator of nuclear factor-kappa B (RANK) and receptor activator of nuclear factor-kappa B ligand (RANKL), the members of the tumor necrosis factor (TNF) family, have multiple effects on bone metabolism, endocrine functions and, as an inflammatory pathway, in the immune system. This study tried to determine the association of the OPG/RANKL/RANK axis with the severity of unstable angina (UA) as an inflammatory condition. Our study involved 50 patients with UA and 50 healthy people. Serum and peripheral blood mononuclear cells were isolated from all participants. Serum levels and gene expression of OPG, RANKL, and RANK in mononuclear cells were measured by enzyme-linked immunosorbent assay (ELISA) and real-time polymerase chain reaction (RT-PCR), respectively. For each patient with UA, the thrombolysis in myocardial infarction (TIMI) and the global registry of acute coronary events (GRACE) scores were determined to evaluate the severity of the disease. Then we analyzed the relation of OPG, RANKL, and RANK levels with TIMI and GRACE scores in patients with UA. Discriminate analysis was used to predict the combinational models of such factors on the prediction of UA. Serum levels of OPG and RANKL (p<0.001) and gene expression of RANKL (p<0.001) were significantly more in patients than those in healthy ones. No relation was seen between the OPG/RANKL/RANK axis and the severity of UA according to TIMI and GRACE scores. Our study shows that serum level, as well as gene expression of OPG/RANKL/RANK axis neither, predicts the occurrence of UA nor shows any relationship with its severity.

Comparison of the effect of ticagrelor combined with tirofiban versus clopidogrel combined with tirofiban on inflammation response and prognosis of patients with unstable angina pectoris in long term follow-up.

To investigate the effect of ticagrelor combined with tirofiban versus clopidogrel combined with tirofiban on inflammation response and prognosis of patients with unstable angina pectoris (UA). The present prospective study included a total of 291 patients who were diagnosed as unstable UA from January 2018 to December 2019. All UA patients were divided into two groups: ticagrelor combined with tirofiban group (n = 159) and clopidogrel combined with tirofiban group (n = 132). Serum levels of C-reactive protein (CRP), interleukin-1ß, interleukin-6, tumor necrosis factor-α, and matrix metalloproteinase-9 were measured using commercially available enzyme-linked immunosorbent assay kits. Kaplan-Meier (K-M) curve was performed for analysis of cumulative incidences of major adverse cardiovascular events (MACEs). Both ticagrelor combined with tirofiban and clopidogrel combined with tirofiban significantly decreased the serum levels of inflammatory factors in UA patients. Compared to clopidogrel combined with the tirofiban group, ticagrelor combined with the tirofiban group had a lower platelet aggregation rate and improved cardiac function of UA patients. Besides, ticagrelor combined with tirofiban group had a better prognosis and the K-M curve showed that UA patients treated by ticagrelor and tirofiban had lower incidences of MACEs in one-year follow-up. The treatment of ticagrelor combined with tirofiban significantly attenuated inflammation response and improved the prognosis of UA patients.

[Coronary artery bypass grafting in myocardial infarction and unstable angina pectoris: in-hospital outcomes. Part 2]. / Koronarnoe shuntirovanie pri infarkte miokarda i nestabil'noi stenokardii: gospital'nye iskhody. Chast' 2.

AIM: To assess in-hospital outcomes of coronary artery bypass grafting in patients with acute coronary syndrome, depending on the presence or absence of myocardial infarction. PATIENTS AND METHODS: Over the period from 2017 to 2018 within the framework of a single-centre register, the study enrolled a total of 166 consecutive patients admitted with non-ST segment elevation acute coronary syndrome and subjected to coronary artery bypass grafting. Depending on the outcome of acute coronary syndrome, the patients were divided into 2 groups: Group One included 98 (59%) patients with unstable angina pectoris and Group Two comprised 68 (41%) patients with myocardial infarction, who underwent surgery at an average of 16 (11; 20) days after manifestation of the clinical signs of myocardial infarction. The endpoints of the study were major adverse cardiovascular events during the in-hospital period: death, myocardial infarction, acute cerebral circulation impairment/transitory ischaemic attack, repeat revascularization, septic complications, multiple organ failure syndrome, wound infectious complications, requirement for repeated surgical debridement, remediastinotomy due to haemorrhage, the frequency of extracorporeal membrane oxygenation and renal replacement therapy. RESULTS: The mortality rate in the compared groups was similar: 3% (n=3) and 3% (n=2), respectively. Perioperative myocardial infarction occurred in 1 (1%) patient of the first group, with no cases of this complication observed in the second group. The frequency of reoperations due to haemorrhage in the early postoperative period in the group of unstable angina pectoris amounted to 3% (n=3) and was associated with administration of dual antithrombotic therapy, with no cases of this complication in the group of myocardial infarction. Wound complication in the second group were observed in 7.6% (n=5) and in the first group in 4% (n=4) (p=0.33). The differences turned out to be statistically insignificant for such postoperative complications as multiple organ failure syndrome, requirement for repeated surgical debridement, renal replacement therapy, and extracorporeal membrane oxygenation. The residual SYNTAX Score in the group of myocardial infarction amounted to 2.3±2.8, whereas in the group of unstable angina pectoris to 2.3±3, thus suggesting complete revascularization in the total sample of patients with acute coronary syndrome. The average length of hospital stay (including the postoperative period) in the first group amounted to 26.3±6.6 days and in the second group to 27.4±7.2 days (p=0.53). The postoperative bed-day in the group with unstable angina pectoris was 12.6±3.2 and in the myocardial infarction group - 14.9±5.3 (p=0.06). CONCLUSION: The obtained in-hospital outcomes suggest that coronary artery bypass grafting may be an efficient and safe method of complete revascularization for patients with non-ST-elevation acute coronary syndrome, including that resulting in myocardial infarction, performed averagely on day 16 (11; 20) after the onset of clinical manifestations of myocardial infarction.

Unmasking the Coronary-Subclavian Steal Syndrome: The Culprit Lies in the Subclavian Artery. A Report of a Case and Review of the Literature.

The coronary-subclavian steal syndrome is a hemodynamic phenomenon in which a subclavian artery stenosis or occlusion impairs blood flow at the origin of the left internal mammary artery used for coronary artery bypass grafting (CABG), causing retrograde blood flow and thus provoking symptoms of cardiac ischemia and its complications. Once considered the gold-standard operation of choice, open revascularization has now been abandoned as a first line treatment and replaced by endovascular techniques. In all cases, detailed and oriented physical examination in combination with further imaging in high clinical suspicion for coronary-subclavian steal syndrome remains the sine qua non of the preoperative examination of the patient. We report the case of a 50-year-old male patient suffering from acute onset angina post- coronary artery bypass grafting and managed by endovascular means.

[Coronary artery bypass grafting in myocardial infarction and unstable angina pectoris: analysis of perioperative factors. Part 1]. / Koronarnoe shuntirovanie pri infarkte miokarda i nestabil'noi stenokardii: analiz perioperatsionnykh faktorov. Chast' 1.

AIM: The purpose of this study was to assess the perioperative clinical, demographic and anatomo-angiographic factors in patients presenting with non-ST-segment elevation acute coronary syndrome and being candidates for coronary artery bypass grafting, depending on the presence or absence of myocardial infarction. PATIENTS AND METHODS: Over the period from 2017 to 2018 within the framework of a single-centre register, the study enrolled a total of 166 consecutive patients admitted with non-ST segment elevation acute coronary syndrome and recommended by the cardiosurgical team to undergo coronary artery bypass grafting. Depending on the outcome of acute coronary syndrome, the patients were divided into 2 groups: Group One included 98 (59%) patients with unstable angina pectoris and Group Two comprised 68 (41%) patients with myocardial infarction. A lethal outcome occurred in 2 (3%) Group Two patients prior to revascularization, hence they were not included into the analysis comparing the results of surgery in both groups, however these data were taken into consideration, being analysed separately. RESULTS: The group of patients with myocardial infarction appeared to include significantly more female patients (20 (30.3%) versus 15 (15.3%) in the group of patients with unstable angina pectoris, p=0.02). However, by such parameters as the average age, left ventricular ejection fraction, and the frequency of diabetes mellitus the compared groups did not differ. The group with myocardial infarction was characterised by a severe clinico-angiographic status: more frequently encountered was stage II obesity (3%, n=3 in the first group and 10.6% n=7 in the second group, p=0.04). On the whole, the majority of patients were at intermediate and high risk (44.7% in the group with unstable angina pectoris versus 81.8% in the group of myocardial infarction, p<0.05). Group Two patients significantly more often presented with three-vessel lesions of the coronary bed (40 (40.8%) and 39 (59%), p=0.02). The level of low-density lipoproteins appeared to be significantly higher in patients with myocardial infarction (3.3±1 mmol/l and 2.9±0.9, p=0.04). In the same group more often encountered were peripheral artery lesions (28 (21%) and 12 (11.3%), p=0.04). In its turn, in the group of unstable angina pectoris, there were significantly more patients having received dual antithrombotic therapy prior to surgery (44 (44.9%) and 17 (25%), p=0.01). Approximately half of the patients in the first group (53%, n=52) had a history of myocardial infarction (p=0.001). CONCLUSION: The obtained findings suggested that amongst the patients with non-ST-elevation acute coronary syndrome resulting in myocardial infarction prevailing were those of female gender, with obesity, as a consequence, hyperholesterolaemia and triple-vessel disease. At the same time, postinfarction cardiosclerosis, renal dysfunction, and haemodynamically significant lesions of lower-extremity arteries were encountered in the group of unstable angina pectoris.

Pathways leading to prevention of fatal and non-fatal cardiovascular disease: An interaction model on 15 years population-based cohort study.

BACKGROUND: A comprehensive study on the interaction of cardiovascular disease (CVD) risk factors is critical to prevent cardiovascular events. The main focus of this study is thus to understand direct and indirect relationships between different CVD risk factors. METHODS: A longitudinal data on adults aged ≥35 years, who were free of CVD at baseline, were used in this study. The endpoints were CVD events, whereas their measurements were demographic, lifestyle components, socio-economics, anthropometric measures, laboratory findings, quality of life status, and psychological factors. A Bayesian structural equation modelling was used to determine the relationships among 21 relevant factors associated with total CVD, stroke, acute coronary syndrome (ACS), and fatal CVDs. RESULTS: In this study, a total of 3161 individuals with complete information were involved in the study. A total of 407 CVD events, with an average age of 54.77(10.66) years, occurred during follow-up. The causal associations between six latent variables were identified in the causal network for fatal and non-fatal CVDs. Lipid profile, with the coefficient of 0.26 (0.01), influenced the occurrence of CVD events as the most critical factor, while it was indirectly mediated through risky behaviours and comorbidities. Lipid profile at baseline was influenced by a wide range of other protective factors, such as quality of life and healthy lifestyle components. CONCLUSIONS: Analysing a causal network of risk factors revealed the flow of information in direct and indirect paths. It also determined predictors and demonstrated the utility of integrating multi-factor data in a complex framework to identify novel preventable pathways to reduce the risk of CVDs.

Association Between Early Severe Cardiovascular Events and the Initiation of Treatment With the Anti-Interleukin 12/23p40 Antibody Ustekinumab.

Importance: Ustekinumab, a monoclonal antibody targeting interleukin 12/23p40 (IL-12/23p40), is effective in the treatment of moderate to severe psoriasis, psoriatic arthritis, and Crohn disease. In 2011, a meta-analysis of randomized clinical trials reported a potential risk of severe cardiovascular events (SCEs) within the first few months after the initiation of anti-IL-12/23p40 antibodies. Objective: To assess whether the initiation of ustekinumab treatment is associated with increased risk of SCEs. Design, Setting, and Participants: This case-time-control study used data from the French national health insurance database, covering 66 million individuals, on all patients exposed to ustekinumab between April 1, 2010, and December 31, 2016, classified according to their cardiovascular risk level (high- and low-risk strata). The risk period was the 6 months before the SCE, defined as acute coronary syndrome or stroke, and the reference period was the 6 months before the risk period. Statistical analysis was performed from September 20, 2017, to July 6, 2018. Exposure: The initiation of ustekinumab treatment was screened during the risk and reference periods. Main Outcomes and Measures: Odds ratios for the risk of SCE after the initiation of ustekinumab treatment were calculated. Results: Of the 9290 patients exposed to ustekinumab (4847 men [52%]; mean [SD] age, 43 [14] years), 179 experienced SCEs (65 cases of acute coronary syndrome, 68 cases of unstable angina, and 46 cases of stroke). Among patients with a high cardiovascular risk, a statisically significant association between initiaton of ustekinumab treatment and SCE occurrence was identified (odds ratio, 4.17; 95% CI, 1.19-14.59). Conversely, no statistically significant association was found among patients with a low cardiovascular risk (odds ratio, 0.30; 95% CI, 0.03-3.13). Conclusions and Relevance: This study suggests that the initiation of ustekinumab treatment may trigger SCEs among patients at high cardiovascular risk. In line with the current mechanistic models for atherosclerotic disease, the period after the initiation of anti-IL-12/23p40 may be associated with atherosclerotic plaque destabilization via the inhibition of helper T cell subtype 17. Although the study interpretation is limited by its observational design, these results suggest that caution may be needed in the prescription of ustekinumab to patients at high cardiovascular risk.

Serum Levels of Cystatin C, N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP), and Cardiac Function in Patients with Unstable Angina Pectoris.

BACKGROUND This study aimed to investigate the association between serum levels of cystatin C, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and cardiac function in patients with unstable angina pectoris (UAP). MATERIAL AND METHODS A cross-sectional observational study was conducted at a single center and recruited 300 patients (214 men and 86 women), who were diagnosed with UAP between June 2018 to December 2018. The patients had serum levels of NT-ProBNP measured and were divided into four groups according to the serum levels of cystatin C: Q1, 0.49-0.83 mg/L; Q2, 0.84-1.04 mg/L; Q3, 1.05-1.38 mg/L; Q4, 1.39-4.21 mg/L. Cardiac function was graded according to the New York Heart Association (NYHA) class I to IV criteria. RESULTS In the 300 patients with UAP, there were significant differences in cardiac function and NT-ProBNP levels between the four study groups (Q1 to Q4) (p<0.05). Univariate analysis showed that body weight, heart rate, treatment with aspirin, ticagrelor, angiotensin-converting enzyme inhibitor and an angiotensin receptor blocker (ACE/ARB), diuretic use, uric acid level, and serum cystatin C levels were significantly associated with increased levels of NT-ProBNP. After adjusting for confounding factors screened in univariate analysis, multivariate regression analysis showed that increased serum cystatin C levels were significantly associated with increased levels of NT-ProBNP. CONCLUSIONS Increased serum levels of cystatin C were associated with poor cardiac function and increased levels of NT-ProBNP in patients with UAP.

First Reported Case of Skin Necrosis Due to Prolonged Mechanical Compression After Transradial Catheterization.

We present a patient under triple-antithrombotic therapy who underwent prolonged mechanical compression after radial intervention; the subsequent necrosis at the access site required surgical repair.