Contemporary differences between men and women with acute coronary syndromes: CIAM multicenter registry.

AIM: Differences exist in the diagnosis and treatment of acute coronary syndrome (ACS) between men and women. However, recent advancements in the management of ACSs might have attenuated this sex gap. We evaluated the status of ACS management in a multicenter registry in 10 tertiary Spanish hospitals. METHODS: We enrolled 1056 patients in our study, including only those with type 1 myocardial infarctions or unstable angina presumably not related to a secondary cause in an 'all-comers' design. RESULTS: The women enrolled (29%) were older than men (71.0 ±â€Š12.8 vs. 64.0 ±â€Š12.3, P = 0.001), with a higher prevalence of hypertension (71.0 vs. 56.5%, P < 0.001), insulin-treated diabetes (13.7 vs. 7.9%, P = 0.003), dyslipidemia (62.2 vs. 55.3%, P = 0.038), and chronic kidney disease (16.9 vs. 9.1%, P = 0.001). Women presented more frequently with back or arm pain radiation (57.3 vs. 49.7%, P = 0.025), palpitations (5.9 vs. 2.0%, P = 0.001), or dyspnea (33.0 vs. 19.4%, P = 0.001). ACS without significant coronary stenosis was more prevalent in women (16.8 vs. 8.1%, P = 0.001). There were no differences in percutaneous revascularization rates, but drug-eluting stents were less frequently employed in women (75.4 vs. 67.8%, P = 0.024); women were less often referred to a cardiac rehabilitation program (19.9 vs. 33.9%, P = 0.001). There were no significant differences in in-hospital complications such as thrombosis or bleeding. CONCLUSION: ACS presenting with atypical symptoms and without significant coronary artery stenosis is more frequent in women. Selection of either an invasive procedure or conservative management is not influenced by sex. Cardiac rehabilitation referral on discharge is underused, especially in women.

Assessment of Relationship Between C-Reactive Protein to Albumin Ratio and Coronary Artery Disease Severity in Patients With Acute Coronary Syndrome.

The association of coronary artery disease (CAD) severity with increased C-reactive protein (CRP) and decreased albumin levels has been reported. However, to our knowledge, no study has investigated the usefulness of the CRP to albumin ratio (CAR) in predicting intermediate-high SYNergy between Percutaneous Coronary Intervention with TAXus and cardiac surgery (SYNTAX) score (SS) and high SS II. Consecutive patients (n = 344) treated with percutaneous coronary intervention comprised the study population. The study population was divided into 2 groups according to SS >22 and mean SS II values, respectively. Patients with intermediate-high SS and high SS II had higher CAR than patients with low SS and SS II. History of diabetes mellitus, decreased albumin, lower left ventricular ejection fraction, and elevated CAR (odds ratio [OR]: 1.020; 95% confidence interval [CI], 1.009-1.031; P < .001) were independent predictors of high SS. The presence of hypertension, decreased hemoglobin and albumin levels, and increased CAR (OR: 1.014; 95% CI, 1.004-1.023; P < .001) were independent predictors of SS II. In receiver operating characteristic curve comparison, CAR was superior to CRP and albumin in prediction of intermediate-high SS, but only CRP in prediction of high SS II. The CAR calculated from the admission blood samples could be a useful parameter for predicting CAD severity using SS and SS II.

Echolucency of carotid plaque is useful for assessment of residual cardiovascular risk in patients with chronic coronary artery disease who achieve LDL-C goals on statin therapy.

BACKGROUND: Ultrasound assessment of either intima-media thickness (IMT) or plaque echolucency of the carotid artery provides prognostic information on coronary events. This study examined the hypothesis that IMT and plaque echolucency of the carotid artery may remain useful for prediction of coronary events in patients with coronary artery disease (CAD) after achievement of LDL-C goals on statin therapy. METHODS AND RESULTS: Ultrasound assessment of carotid maximum IMT (maxIMT) and plaque echolucency with integrated backscatter (IBS) analysis was performed in 357 chronic CAD patients with LDL-C <100mg/dl on statin therapy. All patients were prospectively followed up until the occurrence of one of the following coronary events: cardiac death, non-fatal myocardial infarction, or unstable angina pectoris requiring unplanned revascularization. During a mean follow-up of 32±18 months, 33 coronary events occurred. On multivariate Cox proportional hazards analysis, plaque echolucency (lower IBS value) was a significant predictor of coronary events (HR, 0.44; 95% CI: 0.29-0.73; P=0.009), whereas maxIMT was not. The addition of plaque echolucency to traditional risk factors improved net reclassification improvement (NRI) and integrated discrimination improvement (IDI; NRI, 0.59; P=0.0013; and IDI, 0.075; P=0.0009). CONCLUSIONS: Measurement of echolucency of the carotid artery was useful for assessment of residual coronary risk in CAD patients after LDL-C goal attainment on statin treatment.

Multislice computed tomographic coronary angiography for quantitative assessment of culprit lesions in acute coronary syndromes.

BACKGROUND: We studied the characteristics of low-density plaque (LDP) burden in patients with acute coronary syndrome (ACS), using 64-slice computed tomography (CT) assessment. Though several CT plaque features such as positive remodelling, adjacent spotty calcification or the presence of LDP have been demonstrated to be associated with unstable plaques, it is still unknown whether their severity and extent present any differences between different types of ACS. METHODS: In 45 subjects with ACS (22 unstable angina and 23 non-ST-elevation myocardial infarction [NSTEMI]), 118 coronary plaques were evaluated using a CT multislice 64 assessment including the burden with atheroma having a CT density below 30, 60, or 100 Hounsfield units (HU), remodelling index and spotty calcification. RESULTS: Culprit lesions tend to be larger in volume (111.11 mm(3) vs 62.25 mm(3); P < 0.0001), have a higher remodelling index (1.27 vs 1.01; P < 0.0001), and present a significantly larger LDP with a density < 30 HU (23.3 mm(3) vs 7.6 mm(3); P < 0.0001) or < 60 HU (33.4 mm(3) vs 16.9 mm(3); P < 0.0001) than nonculprit lesions. The presence of a plaque more than 20 mm(3) in volume with a CT density < 30 HU (P = 0.0009) and the presence of all 3 markers of plaque vulnerability (LDP, spotty calcifications or positive remodelling) (P = 0.01) significantly correlated with the presence of an NSTEMI. CONCLUSIONS: Culprit lesions demonstrated larger plaque volumes, a higher burden with low-density cores, and more intense remodelling than nonculprit lesions, whereas culprit lesions associated with NSTEMI showed a higher burden with lower density cores than those associated with unstable angina.

Morphologic and functional assessment of coronary artery disease--potential application of computed tomography angiography and myocardial perfusion imaging.

BACKGROUND: The role of combined evaluation of myocardial perfusion imaging (MPI; by single-photon emission computed tomography) and computed tomography angiography (CTA) for risk stratification of coronary artery disease was evaluated. For CTA, the extent of luminal stenosis, and also the features of high-risk plaques (HRP, including positive remodeling and low attenuation) were evaluated. METHODS AND RESULTS: A total of 304 patients (65 ± 11 years, male 72%, median follow-up: 24 months) who underwent CTA and MPI were enrolled in the study. Summed stress scores and summed difference scores (SDS) for MPI, stenosis, and HRP were evaluated, and event rates were compared. Cardiac events were defined as acute coronary event including cardiac death or non-fatal acute myocardial infarction, and unstable angina requiring revascularization. Of 304 patients, 51 (16.8%) underwent early revascularization. In the remaining 253 patients, an event occurred in 11 (4.3%). HRP (hazard ratio [HR], 4.75, P=0.00171) and stenosis (+) with SDS >0 (HR, 4.58, P=0.0461) were significant independent predictors of cardiac event. The event rate for stenosis (+) with SDS >0 was significantly higher than others (log-rank P=0.0490). The event rates were significantly different between HRP(+) and HRP(-) (16.1% vs. 2.7%, log-rank P=0.0013). CONCLUSIONS: HRP on CTA was an independent predictor of acute coronary events, as was stenosis (+) with SDS >0, and HRP had increased prognostic value over stenosis and abnormal MPI findings.

Online 3-dimensional rendering of optical coherence tomography images for the assessment of bifurcation intervention.

Three-dimensional optical coherence tomography rendering has been suggested as a method providing additive information for the assessment of the result of percutaneous coronary intervention. However, rendering of such models is very time-consuming and cannot be performed online during the intervention. We present a case in which a new method for 3-dimensional rendering of optical coherence tomography images helped visualize the stent-vessel wall interaction, providing useful information that discouraged further intervention.

Comparison of clinical risk assessment systems in predicting three-vessel coronary artery disease and angiographic culprit lesion in patients with non-ST segment elevated myocardial infarction/unstable angina pectoris.

BACKGROUND: We wanted to compare the values of clinical risk assessments and scoring systems for predicting three-vessel diseases and culprit lesions by coronary angiography in patients with unstable angina pectoris (UAP), or non-ST segment elevation myocardial infarction (NSTEMI). METHODS: A total of 154 consecutive patients, (42 [27.3%] female, and 112 [72.7%] male, mean age: 63.0 ± 12.7 years) with UAP/NSTEMI were enrolled. Rizik and Braunwald classification, ACC/AHA risk assessment system, TIMI, GUSTO, GRACE and PURSUIT risk scores were determined, and the ROC curve was marked in accordance with the presence of three-vessel disease and culprit lesion. RESULTS: In patients with NSTEMI, the rates of three-vessel disease and culprit lesion were demonstrated to be higher. With respect to the presence of three-vessel disease, only the ACC/AHA risk assessment was manifested to have a predictive value. All risk scoring systems were demonstrated to bear predictive values with different sensitivity and specificity. The TIMI and GRACE risk scores were discovered to have higher predictive values. The presence of culprit lesions could not be predicted by any of the risk assessment or scoring systems. CONCLUSIONS: Among risk assessment systems, only the ACC/AHA system can be used to predict three-vessel disease. It is possible to use all risk scoring systems for the same purpose. The predictive values of the TIMI and GRACE risk scores are higher. The culprit lesions cannot be predicted by any of the risk assessment or scoring systems. The use of cardiac enzymes seems more appropriate with very low sensitivity and specificity.

Assessment of tissue characteristics of noncalcified coronary plaques by 64-slice computed tomography in comparison with integrated backscatter intravascular ultrasound.

BACKGROUND: The ability of 64-slice computed tomography (CT) angiography to differentiate plaque types remains unclear. We evaluated whether the density of noncalcified coronary plaques by 64-slice CT angiography correlates with plaque components assessed by integrated backscatter intravascular ultrasound (IB-IVUS). METHODS: Eighty-six patients [stable angina/acute coronary syndrome (ACS) 67/19, mean age 62+/-11 years] who showed significant coronary artery stenosis (> or =50% diameter stenosis) by 64-slice CT angiography underwent coronary angiography and were evaluated using IB-IVUS. RESULTS: A total of 92 noncalcified coronary plaques on CT angiography were evaluated with IB-IVUS. There was a positive correlation between CT density and calcified tissue content (r=0.41, P<0.001). However, the CT density of plaques did not correlate with other tissue components. Patients with ACS showed more lipid (43.1+/-13.2 vs. 35.8+/-13.5, P=0.03) and less soft fibrous tissue (50.5+/-11.7 vs. 56.5+/-12.0, P=0.05) by IB-IVUS than those with stable angina. However, the mean CT density of plaques in ACS was not different from that in stable angina (140.6+/-88.5 vs. 113.1+/-80.9, P=0.19). CONCLUSION: Except for calcified tissue, CT angiography failed to differentiate plaque types of noncalcified tissue. Therefore, the role of 64-slice CT angiography in identifying lipid-rich plaques remains limited.

Prediction of cardiac events in patients with reduced left ventricular ejection fraction with dobutamine cardiovascular magnetic resonance assessment of wall motion score index.

OBJECTIVES: The purpose of this study was to assess the utility of dobutamine cardiovascular magnetic resonance (DCMR) results for predicting cardiac events in individuals with reduced left ventricular ejection fraction (LVEF). BACKGROUND: It is unknown whether DCMR results identify a poor cardiac prognosis when the resting LVEF is moderately to severely reduced. METHODS: Two hundred consecutive patients ages 30 to 88 (average 64) years with an LVEF 40%. CONCLUSIONS: In individuals with mild to moderate reductions in LVEF (40% to 55%), dobutamine-induced increases in WMSI forecast MI and cardiac death to a greater extent than an assessment of resting LVEF. In those with an LVEF <40%, a dobutamine-induced increase in WMSI does not predict MI and cardiac death beyond the assessment of resting LVEF.

Diagnostic performance of 64-channel multislice computed tomography in assessment of significant coronary artery disease in symptomatic subjects.

The recent development of 64-channel multislice computed tomography (MSCT) has resulted in noninvasive coronary artery imaging improvement. This study was conducted to determine the accuracy of 64-slice MSCT in a relatively unselected group of 143 patients with presentations suggestive of coronary artery disease, including those with unstable angina pectoris, who underwent both coronary computed tomographic angiography and invasive coronary angiography. No arrhythmia was considered an exclusion criterion except for atrial fibrillation or frequent extrasystoles. In patients with fast heart rates, a beta blocker was administered orally. Data were obtained using electrocardiography gated 64-slice MSCT. Computed tomographic angiography and invasive coronary angiography findings of each coronary segment were compared to determine the sensitivity, specificity, positive predictive value, and negative predictive value of MSCT in the detection of their normalcy or insignificant (<50% diameter decrease) stenosis versus significant (>or=50% diameter decrease) stenosis or total occlusion. In per-patient assessment, the calculated sensitivity, specificity, positive predictive value, and negative predictive value of MSCT were 96%, 67%, 91%, and 83%, respectively. These values in per-artery evaluation were 94%, 94%, 87%, and 97%, and corresponding values in per-segment analysis were 92%, 97%, 77%, and 99%, respectively. In conclusion, computed tomographic angiography has high diagnostic performance in the assessment of significant coronary artery disease in most patients in a daily routine practice, including those presenting with unstable angina pectoris symptoms.

Sequential transthoracic ultrasound assessment of coronary flow reserve in a patient with Tako-tsubo syndrome.

We report a case of a 70-year-old woman with Tako-tsubo syndrome admitted to the hospital with typical chest pain and electrocardiogram changes in anterior precordial leads suggesting acute coronary syndrome. Coronary angiography demonstrated normal coronary artery and left ventriculography the typical apical ballooning of Tako-tsubo syndrome. Transthoracic echocardiographically derived coronary flow velocity reserve by adenosine was lower than normal (1.54) in the acute phase and improved after 1 month (2.68). At this time, electrocardiogram normalization also occurred. Our report supports the hypothesis that coronary microvascular dysfunction might be a determinant of Tako-tsubo syndrome.

[Coronary artery plaque assessment using Volcano Therapeutics' Virtual Histology intravascular ultrasound and temperature guide wire].

OBJECTIVES: This study investigated the tissue characterization of human coronary artery plaque using Virtual Histology intravascular ultrasound (VH-IVUS) and temperature guide wire. METHODS AND RESULTS: Between August 2005 and December 2005, VH-IVUS examination and guide wire based measurement of coronary temperature were performed in 66 patients: 39 with stable angina pectoris (SAP), and 27 with unstable angina pectoris(UAP). Patients in the acute myocardial infarction with necrotic tissue and thrombus were excluded. After measurement of distal coronary pressure and coronary temperature, the following tissue types of atherosclerotic plaque were evaluated by VH-IVUS: fibrotic, fibro-fatty, dense calcium and necrotic core. Occurrence of fibro-fatty tissue was significantly higher in UAP patients than in SAP patients (17.4 +/- 7.0% vs 11.2 +/- 5.2%, p = 0.04), and coronary temperature was significantly higher in UAP patients than in SAP patients (0.08 +/- 0.05 vs 0.03 +/- 0.02 degrees C, p = 0.01). CONCLUSIONS: These results suggest that the combination of VH-IVUS analysis and measurement of coronary temperature may be able to predict the progression of lesions.

Imaging in the evaluation of the patient with suspected acute coronary syndrome.

Over the last decade, major advances have been made in the treatment of acute coronary syndromes (ACSs). However, effective implementation of these treatments requires timely and accurate identification of the high-risk patient among all those presenting to the emergency department (ED) with symptoms suggestive of ACS. The opportunity for improving outcomes is time-dependent, so that early identification of the patient who has true ACS is essential. This necessity further increases the need for rapid triage tools, especially in the current setting of ED and hospital overcrowding that has become the norm in large urban centers.

Outpatient coronary angioplasty: feasible and safe.

This study tested the safety and feasibility of coronary angioplasty on an outpatient basis. The purpose of this approach includes cost-effectiveness and patient comfort. Six hundred forty-four patients were randomized to either transradial or transfemoral PTCA using 6 Fr equipment. Patients were triaged to outpatient management based on a predefined set of predictors of an adverse outcome in the first 24 hr after initially successful coronary angioplasty. Three hundred seventy-five patients (58%) were discharged 4-6 hr after PTCA; 42% stayed in hospital overnight. In the outpatient group, one adverse event occurred (subacute stent thrombosis 7 hr postdischarge, nonfatal myocardial infarction). There were no major vascular complications. In the hospital group, 19 patients (7%) sustained an adverse cardiac even in the first 24 hr; 1 patient died. Patients treated via the femoral route had more (minor) bleeding complications (19 patients; 6%); in 17 of these, this was the sole reason that discharge was delayed. PTCA on an outpatient basis, performed via the radial or the femoral artery with low-profile equipment, is safe and feasible in a considerable part of a routine PTCA population. A larger proportion of transradial patients can be discharged due to a reduction in (minor) bleeding complications.

Assessment of the long-term reproducibility of baseline and dobutamine-induced myocardial blood flow in patients with stable coronary artery disease.

UNLABELLED: Although physical exercise is the preferred stimulus for cardiac stress testing, pharmacologic agents are useful in patients who are unable to exercise. Previous studies have demonstrated short-term repeatability of exercise and adenosine stress, but little data exist regarding dobutamine (Dob) stress or the long-term reproducibility of pharmacologic stressors in coronary artery disease (CAD) patients. PET allows accurate, noninvasive quantification of myocardial blood flow (MBF) and coronary flow reserve (CFR). The aim of the study was to investigate the long-term reproducibility of Dob stress on MBF and CFR in CAD patients using PET. METHODS: Fifteen patients with chronic stable angina and angiographically proven CAD (>70% stenosis in at least 1 major coronary artery) underwent PET with (15)O-labeled water and Dob stress at baseline (time [t] = 0) and after 24 wk (t = 24). MBF at rest and MBF during Dob stress were calculated for the whole left ventricle, the region subtended by the most severe coronary artery stenosis (Isc), and remote myocardium subtended by arteries with minimal or no disease (Rem). Reproducibility was assessed using the Bland-Altman (BA) repeatability coefficient and was also expressed as a percentage of the mean value of the 2 measurements (%BA). RESULTS: Dob dose (30 +/- 11 vs. 031 +/- 11 microg/kg/min; P = not significant [ns]) and peak Dob rate.pressure product (20,738 +/- 3,947 vs. 20,047 +/- 3,455 mm Hg x beats/min; P = ns) were comparable at t = 0 and t = 24. There was no significant difference in resting or Dob MBF (mL/min/g) between t = 0 and t = 24 for the whole left ventricle (1.03 +/- 0.19 vs. 1.10 +/- 0.20 and 2.02 +/- 0.44 vs. 2.09 +/- 0.57; P = ns for both), Isc (1.05 +/- 0.24 vs. 1.10 +/- 0.26 and 1.79 +/- 0.53 vs. 1.84 +/- 0.62; P = ns for both), or Rem (1.03 +/- 0.23 vs. 1.10 +/- 0.26 and 2.27 +/- 0.63 vs. 2.26 +/- 0.63; P = ns for both) territories. Global (1.98 +/- 0.40 vs. 1.90 +/- 0.46; P = ns) and regional CFR (Isc: 1.65 +/- 0.40 vs. 1.67 +/- 0.47, and Rem: 2.25 +/- 0.57 vs. 2.06 +/- 0.51; P = ns) were reproducible. The BA repeatability coefficients (and %BA) for MBF in ischemic and remote territories were 0.3 (28%) and 0.26 (24%) at rest and 0.49 (27%) and 0.58 (26%) during Dob stress. CONCLUSION: In patients with clinically stable CAD, Dob induces reproducible changes in both global and regional MBF and CFR over a time interval of 24 wk. The reproducibility of MBF and CFR with Dob was comparable with the short-term repeatability reported for adenosine and physical exercise in healthy subjects.

Nuclear cardiology in acute coronary syndromes.

Acute coronary syndromes are a frequent manifestation of coronary artery disease, usually being associated with chest pain and presenting as a medical emergency. Since a considerable number of patients with chest pain, however, have a non cardiac etiology of their pain, properly triaging these patients represents a diagnostic challenge for physicians in the emergency department. As the available diagnostic procedures have limited accuracy, many different diagnostic strategies have been evaluated. Among these, radionuclide myocardial perfusion imaging (MPI) at rest or in combination with stress procedures has been investigated in many trials. MPI has been proven to be useful, especially in a patient population with a low to intermediate probability of an ischemic event. Perfusion scintigraphy has a high sensitivity in the detection of myocardial infarction and reveals an excellent negative predictive value, allowing a safe discharge strategy of patients with a negative scan result. Moreover, it enables risk stratification and provides incremental and independent prognostic information regarding short to long term future cardiac adverse events. Several cost effectiveness studies have shown that perfusion imaging leads to lower overall direct costs, mainly by a reduction of unnecessary hospital admissions and diagnostic angiograms, without worsening of the clinical outcome of these patients. As a possible study endpoint, myocardial perfusion imaging in the acute setting enables the quantification of salvaged myocardium and therefore the evaluation of treatment efficacy. Besides perfusion agents, several infarct avid radiopharmaceuticals have been developed, which in part show promising results. However, larger randomized trials evaluating these tracers in clinical settings are needed to warrant routine clinical application.