From Wellens' syndrome to acute anterior myocardial infarction, what is required? Only time!

The hallmark of Wellens' syndrome is a distinct modification in the precordial T wave of the electrocardiogram (ECG), which usually indicates substantial stenosis of the proximal left anterior descending artery (LAD). Patients with Wellens' syndrome commonly do not exhibit any symptoms of chest pain. This current case report describes a male patient in his early 60s who presented with sporadic chest pain who was subsequently diagnosed with Wellens' syndrome-related electrocardiographic abnormalities. In the precordial leads V2-V5, an inverted symmetric T wave was visible on the asymptomatic ECG. The inverted symmetric T wave of the precordial lead V2-V5 reverted back to being upright when the chest pain started. A follow-up ECG performed before emergency surgery revealed ventricular premature beats and an increase of 0.1-0.5 mV in the ST segment of the precordial leads V1-V5. A drug-eluting stent was inserted after the patient's coronary angiography revealed proximal stenosis of the LAD. To prevent acute myocardial infarction, emergency physicians must identify the ECG signs of Wellens' syndrome and treat high-risk patients with revascularization as soon as feasible. Early recognition and proactive intervention are crucial, as they may help to alleviate adverse consequences.

Dobutamine stress echocardiography after positive CCTA: diagnostic performance using fractional flow reserve and instantaneous wave-free ratio as reference standards.

AIMS: To assess the diagnostic accuracy of dobutamine stress echocardiography (DSE) in symptomatic patients with a low to intermediate pretest probability of obstructive coronary artery disease (CAD) and a positive coronary CT angiography (CCTA). METHODS: We prospectively enrolled 104 consecutive patients undergoing coronary angiography for symptoms of stable CAD and a CCTA indicative of obstructive CAD. The diagnostic performance of DSE was evaluated against two intracoronary pressure indices: (a) fractional flow reserve (FFR) with a cut-off of ≤0.80 and (b) instantaneous wave-free ratio (iFR) with a cut-off of ≤0.89, indicating haemodynamically significant stenoses. RESULTS: Of 102 patients, 46 (45%) had at least one significant lesion as defined by FFR, as did 37 (36%) as defined by iFR. DSE showed positive results in 33% (34/102) of cases. The discriminative power of DSE for detecting significant CAD was moderate, with areas under the curve of 0.63 (p=0.024) compared with FFR and 0.64 (p=0.025) compared with iFR. The accuracy, sensitivity and specificity of DSE were, respectively, 61%, 43%, and 75% against FFR, and 64%, 46% and 74% against iFR. The diagnostic accuracy of DSE did not differ significantly between FFR and iFR as a reference (p=0.549). CONCLUSION: In patients with positive CCTA, DSE has a moderate ability to identify haemodynamically significant CAD, with low sensitivity and moderate specificity. When assessed against FFR and iFR criteria, its additive diagnostic value is limited in patients with low to intermediate pretest probability of obstructive CAD. TRIAL REGISTRATION NUMBER: NCT03045601.

Intracoronary ECG ST-segment shift remission time during reactive myocardial hyperemia: a new method to assess hemodynamic coronary stenosis severity.

Fractional flow reserve (FFR) measurements are recommended for assessing hemodynamic coronary stenosis severity. Intracoronary ECG (icECG) is easily obtainable and highly sensitive in detecting myocardial ischemia due to its close vicinity to the myocardium. We hypothesized that the remission time of myocardial ischemia on icECG after a controlled coronary occlusion accurately detects hemodynamically relevant coronary stenosis. This retrospective, observational study included patients with chronic coronary syndrome undergoing hemodynamic coronary stenosis assessment immediately following a strictly 1-min proximal coronary artery balloon occlusion with simultaneous icECG recording. icECG was used for a beat-to-beat analysis of the ST-segment shift during reactive hyperemia immediately following balloon deflation. The time from coronary balloon deflation until the ST-segment shift reached 37% of its maximum level, i.e., icECG ST-segment shift remission time (τ-icECG in seconds), was obtained by an automatic algorithm. τ-icECG was tested against the simultaneously obtained reactive hyperemia FFR at a threshold of 0.80 as a reference parameter. From 120 patients, 139 icECGs (age, 68 ± 10 yr old) were analyzed. Receiver operating characteristic (ROC) analysis of τ-icECG for the detection of hemodynamically relevant coronary stenosis at an FFR of ≤0.80 was performed. The area under the ROC curve was equal to 0.621 (P = 0.0363) at an optimal τ-icECG threshold of 8 s (sensitivity, 61%; specificity, 67%). τ-icECG correlated inversely and linearly with FFR (P = 0.0327). This first proof-of-concept study demonstrates that τ-icECG, a measure of icECG ST segment-shift remission after a 1-min coronary artery balloon occlusion accurately detects hemodynamically relevant coronary artery stenosis according to FFR at a threshold of ≥8 s.NEW & NOTEWORTHY Invasive hemodynamic measurements are recommended by the current cardiology guidelines to guide percutaneous coronary interventions in the setting of chronic coronary syndrome. However, those pressure-derived indices demonstrate several theoretical and practical limitations. Thus, this study demonstrates the accuracy of a novel, pathophysiology-driven approach using intracoronary ECG for the identification of hemodynamically relevant coronary lesions by quantitatively assessing myocardial ischemia remission.

Murray law-based quantitative flow ratio for assessment of nonculprit lesions in patients with ST-segment elevation myocardial infarction.

INTRODUCTION: Revascularization of nonculprit arteries in patients with ST-Segment Elevation Myocardial Infarction (STEMI) is now recommended based on several trials. However, the optimal therapeutic strategy of nonculprit lesions remains unknown. Murray law-based Quantitative Flow Ratio (µQFR) is a novel, non-invasive, vasodilator-free method for evaluating the functional severity of coronary artery stenosis, which has potential applications for nonculprit lesion assessment in STEMI patients. MATERIAL AND METHODS: Patients with STEMI who received staged PCI before hospital discharge were enrolled retrospectively. µQFR analyses of nonculprit vessels were performed based on both acute and staged angiography. RESULTS: Eighty-four patients with 110 nonculprit arteries were included. The mean acute µQFR was 0.76 ± 0.18, and the mean staged µQFR was 0.75 ± 0.19. The average period between acute and staged evaluation was 8 days. There was a good correlation (r = 0.719, P < 0.001) between acute µQFR and staged µQFR. The classification agreement was 89.09%. The area under the receiver operator characteristic (ROC) curve for detecting staged µQFR ≤ 0.80 was 0.931. CONCLUSIONS: It is feasible to calculate the µQFR during the acute phase of STEMI patients. Acute µQFR and staged µQFR have a good correlation and agreement. The µQFR could be a valuable method for assessing functional significance of nonculprit arteries in STEMI patients.

Noninvasive and fast method of calculation for instantaneous wave-free ratio based on haemodynamics and deep learning.

BACKGROUND AND OBJECTIVES: Instantaneous wave-free ratio (iFR) is a new invasive indicator of myocardial ischaemia, and its diagnostic performance is as good as the "gold standard" of myocardial ischaemia diagnosis: fractional flow reserve (FFR). iFR can be approximated by iFRCT, which is calculated based on noninvasive coronary CT angiography (CTA) images and computational fluid dynamics (CFD). However, the existing methods for calculating iFRCT fail to accurately simulate the resting state of the coronary artery, resulting in low computational accuracy. Furthermore, the use of CFD technology limits its computational efficiency, making it difficult to meet clinical application needs. The role of coronary microcirculatory resistance compensation suggests that microcirculatory resistance can be adaptively reduced to compensate for increases in coronary stenotic resistance, thereby maintaining stable myocardial perfusion in the resting state. It is therefore necessary to consider this compensation mechanism to establish a high-fidelity microcirculation resistance model in the resting state in line with human physiology, and so to achieve accurate calculation of iFRCT. METHODS: In this study we successfully collected clinical data, such as FFR, in 205 stenotic vessels from 186 patients with coronary heart disease. A neural network model was established to predict coronary artery stenosis resistance. Based on the compensation mechanism of coronary microcirculation resistance, an iterative solution algorithm for microcirculation resistance in the resting state was developed. Combining the two methods, a simplified single-branch model combining coronary stenosis and microcirculation resistance was established, and the noninvasive and rapid numerical calculation of iFRCT was performed. RESULTS: The results showed that the mean squared error (MSE) between the pressure drop predicted by the neural network value for the coronary artery stenosis model and the ground truth in the test set was 0.053 %, and correlation analysis proved that there was a good correlation between them (r = 0.99, p < 0.001). With reference to clinical diagnosis of myocardial ischaemia (using FFR as the gold standard), the diagnostic accuracy of the iFRCT calculation model for the 205 cases was 88.29 % (r = 0.71, p < 0.001), and the total calculation time was < 8 s. CONCLUSIONS: The results of this study demonstrate the utility of a simplified single-branch model in an iFRCT calculation method based on haemodynamics and deep learning, which is important for noninvasive and rapid diagnosis of myocardial ischaemia.

Wellens Syndrome in a patient with a history of hypertension and chronic obstructive pulmonary disease: a case report.

Wellens syndrome, an ST Elevation Myocardial Infarction (STEMI) equivalent, is also known as T-wave left anterior descending (LAD) coronary artery disease. Wellens syndrome is characterized by a unique electrocardiogram (ECG) pattern that suggests a significant stenosis in the left anterior descending coronary artery that warrants immediate intervention. Hereby, we present a case report of Wellens syndrome in a patient with a history of hypertension and chronic obstructive pulmonary disease (COPD) that may be potentially mistaken for pseudo- Wellens syndrome because the ECG pattern mimics left ventricular strain pattern (LVSP) in left ventricular hypertrophy (LVH). Thus, cautious examination of recent chest pain and ECG is important to differentiate Wellens syndrome and LVSP in patients with hypertension and COPD to perform early detection and aggressive intervention since they may help to lessen the adverse results.

Headache as the sole clinical manifestation of acute myocardial infarction: one case with cardiac cephalalgia and literature review.

OBJECTIVE: Cardiac cephalalgia, once seen as a rare symptom of coronary artery disease, is now more recognized. It often comes with chest discomfort and autonomic dysfunction, worsened by physical activity. However, not all cases have chest symptoms or are activity induced. This report presents a case of cardiac cephalalgia and reviews 46 previous cases. METHOD: We discuss a unique case where a patient had headache attacks without chest symptoms, autonomic dysfunction, or triggers. We reviewed English case reports of cardiac cephalalgia from 1982 to 2022 using PubMed ( http://www.ncbi.nlm.nih.gov/pubmed ). RESULTS: A 69-year-old man presented with a sudden headache without triggers or typical symptoms. Coronary computed tomography angiography (CTA) showed diffuse stenosis in the left anterior descending and the first diagonal branch arteries. His headache improved after percutaneous coronary intervention. Cardiac cephalalgia is usually marked by severe headaches, autonomic signs, and often affects the occipital region. Electrocardiogram (ECG) might not always show abnormalities, and chest pain is not always present. In such cases, elevated cardiac enzymes can be crucial for diagnosis. CONCLUSION: When a headache is the sole symptom of an acute coronary event, consider moderate to severe intensity, older age at onset, occipital localization, and autonomic signs. ECG, cardiac enzymes, and coronary CTA are valuable for accurate diagnosis and treatment.

Diagnostic Performance of Coronary Angiography Derived Computational Fractional Flow Reserve.

BACKGROUND: Computational fluid dynamics can compute fractional flow reserve (FFR) accurately. However, existing models are limited by either the intravascular hemodynamic phenomarkers that can be captured or the fidelity of geometries that can be modeled. METHODS AND RESULTS: This study aimed to validate a new coronary angiography-based FFR framework, FFRHARVEY, and examine intravascular hemodynamics to identify new biomarkers that could augment FFR in discerning unrevascularized patients requiring intervention. A 2-center cohort was used to examine diagnostic performance of FFRHARVEY compared with reference wire-based FFR (FFRINVASIVE). Additional biomarkers, longitudinal vorticity, velocity, and wall shear stress, were evaluated for their ability to augment FFR and indicate major adverse cardiac events. A total of 160 patients with 166 lesions were investigated. FFRHARVEY was compared with FFRINVASIVE by investigators blinded to the invasive FFR results with a per-stenosis area under the curve of 0.91, positive predictive value of 90.2%, negative predictive value of 89.6%, sensitivity of 79.3%, and specificity of 95.4%. The percentage ofdiscrepancy for continuous values of FFR was 6.63%. We identified a hemodynamic phenomarker, longitudinal vorticity, as a metric indicative of major adverse cardiac events in unrevascularized gray-zone cases. CONCLUSIONS: FFRHARVEY had high performance (area under the curve: 0.91, positive predictive value: 90.2%, negative predictive value: 89.6%) compared with FFRINVASIVE. The proposed framework provides a robust and accurate way to compute a complete set of intravascular phenomarkers, in which longitudinal vorticity was specifically shown to differentiate vessels predisposed to major adverse cardiac events.

Use of coronary physiology to guide revascularization in clinical practice: results of the F(FR)2 registry.

BACKGROUND: Despite the recommendation of coronary physiology to guide revascularization in angiographically intermediate stenoses without established correlation to ischemia, its uptake in clinical practice is slow. AIMS: This study aimed to analyze the use of coronary physiology in clinical practice. METHODS: Based on a multicenter registry (Fractional Flow Reserve Fax Registry, F(FR)2, ClinicalTrials.gov identifier NCT03055910), clinical use, consequences, and complications of coronary physiology were systematically analyzed. RESULTS: F(FR)2 enrolled 2,000 patients with 3,378 intracoronary pressure measurements. Most measurements (96.8%) were performed in angiographically intermediate stenoses. Out of 3,238 lesions in which coronary physiology was used to guide revascularization, revascularization was deferred in 2,643 (78.2%) cases. Fractional flow reserve (FFR) was the most common pressure index used (87.6%), with hyperemia induced by an intracoronary bolus of adenosine in 2,556 lesions (86.4%) and intravenous adenosine used for 384 measurements (13.0%). The route of adenosine administration did not influence FFR results (change-in-estimate -3.1% for regression model predicting FFR from diameter stenosis). Agreement with the subsequent revascularization decision was 93.4% for intravenous and 95.0% for intracoronary adenosine (p = 0.261). Coronary artery occlusion caused by the pressure wire was reported in two cases (0.1%) and dissection in three cases (0.2%), which was fatal once (0.1%). CONCLUSIONS: In clinical practice, intracoronary pressure measurements are mostly used to guide revascularization decisions in angiographically intermediate stenoses. Intracoronary and intravenous administration of adenosine seem equally suited. While the rate of serious complications of wire-based intracoronary pressure measurements in clinical practice seems to be low, it is not negligible.

Impact of hyperaemic stenosis resistance on long-term outcomes of stable angina in the ILIAS Registry.

BACKGROUND: The hyperaemic stenosis resistance (HSR) index was introduced to provide a more comprehensive indicator of the haemodynamic severity of a coronary lesion. HSR combines both the pressure drop across a lesion and the flow through it. As such, HSR overcomes the limitations of the more traditional fractional flow reserve (FFR) or coronary flow reserve (CFR) indices. AIMS: We aimed to identify the diagnostic and prognostic value of HSR and evaluate the clinical implications. METHODS: Patients with chronic coronary syndromes (CCS) and obstructive coronary artery disease were selected from the multicentre ILIAS Registry. For this study, only patients with combined Doppler flow and pressure measurements were included. RESULTS: A total of 853 patients with 1,107 vessels were included. HSR more accurately identified the presence of inducible ischaemia compared to FFR and CFR (area under the curve 0.71 vs 0.66 and 0.62, respectively; p<0.005 for both). An abnormal HSR measurement was an independent and important predictor of target vessel failure at 5-year follow-up (hazard ratio 3.80, 95% confidence interval: 2.12-6.73; p<0.005). In vessels deferred from revascularisation, HSR seems to identify more accurately those vessels that may benefit from revascularisation rather than FFR and/or CFR. CONCLUSIONS: The present study affirms the theoretical advantages of the HSR index for the detection of ischaemia-Âinducing coronary lesions in a large CCS population. (Inclusive Invasive Physiological Assessment in Angina Syndromes Registry [ILIAS Registry], ClinicalTrials.gov: NCT04485234).

The Plaque Analysis Classifies the Coronary Artery Disease-Reporting and Data System (CAD-RADS) Stenosis and Plaque Burden Categories: Association of the Plaque Features, Fat Attenuation Index, Coronary Computed Tomography Fractional Flow Reserve, and the Combination of Stenosis and Calcification.

BACKGROUND: The coronary artery disease-reporting and data system (CAD-RADS) 2.0 is used to standardize the reporting of coronary computed tomography angiography (CCTA) results. Artificial intelligence software can quantify the plaque composition, fat attenuation index, and fractional flow reserve. OBJECTIVE: To analyze plaque features of varying severity in patients with a combination of CAD-RADS stenosis and plaque burden categorization and establish a random forest classification model. METHODS: The data of 100 patients treated between April 2021 and February 2022 were retrospectively collected. The most severe plaque observed in each patient was the target lesion. Patients were categorized into three groups according to CAD-RADS: CAD-RADS 1-2 + P0-2, CAD-RADS 3-4B + P0-2, and CAD-RADS 3-4B + P3-4. Differences and correlations between variables were assessed between groups. AUC, accuracy, precision, recall, and F1 score were used to evaluate the diagnostic performance. RESULTS: A total of 100 patients and 178 arteries were included. The differences of computed tomography fractional flow reserve (CT-FFR) (H = 23.921, p < 0.001), the volume of lipid component (H = 12.996, p = 0.002), the volume of fibro-lipid component (H = 8.692, p = 0.013), the proportion of lipid component volume (H = 22.038, p < 0.001), the proportion of fibro-lipid component volume (H = 11.731, p = 0.003), the proportion of calcification component volume (H = 11.049, p = 0.004), and plaque type (χ2 = 18.110, p = 0.001) was statistically significant. CONCLUSION: CT-FFR, volume and proportion of lipid and fibro-lipid components of plaques, the proportion of calcified components, and plaque type were valuable for CAD-RADS stenosis + plaque burden classification, especially CT-FFR, volume, and proportion of lipid and fibro-lipid components. The model built using the random forest was better than the clinical model (AUC: 0.874 vs. 0.647).

The Influence of Epicardial Resistance on Microvascular Resistance Reserve.

BACKGROUND: The optimal index of microvascular function should be specific for the microvascular compartment. Yet, coronary flow reserve (CFR), despite being widely used to diagnose coronary microvascular dysfunction (CMD), is influenced by both epicardial and microvascular resistance. Conversely, microvascular resistance reserve (MRR) adjusts for fractional flow reserve (FFR), and thus is theoretically independent of epicardial resistance. OBJECTIVES: The authors tested the hypothesis that MRR, unlike CFR, is not influenced by increasing epicardial resistance, and thus is a more specific index of microvascular function. METHODS: In a cohort of 16 patients who had undergone proximal left anterior descending artery stenting, we created 4 grades of artificial stenosis (no stenosis, mild, moderate, and severe) using a coronary angioplasty balloon inflated to different degrees within the stent. For each stenosis grade, we calculated CFR and MRR using continuous thermodilution (64 measurements of each) to assess their response to changing epicardial resistance. RESULTS: Graded balloon inflation resulted in a significant sequential decrease in mean FFR (no stenosis: 0.82 ± 0.05; mild: 0.72 ± 0.04; moderate: 0.61 ± 0.05; severe: 0.48 ± 0.09; P < 0.001). This translated into a linear decrease in mean hyperemic coronary flow (no stenosis: 170.5 ± 66.8 mL/min; mild: 149.8 ± 58.8 mL/min; moderate: 124.4 ± 53.0 mL/min; severe: 94.0 ± 45.2 mL/min; P < 0.001). CFR exhibited a marked linear decrease with increasing stenosis (no stenosis: 2.5 ± 0.9; mild: 2.2 ± 0.8; moderate: 1.8 ± 0.7; severe: 1.4 ± 0.6), corresponding to a decrease of 0.3 for a decrease in FFR of 0.1 (P < 0.001). In contrast, MRR exhibited a negligible decrease across all stenosis grades (no stenosis: 3.0 ± 1.0; mild: 3.0 ± 1.0; moderate: 2.9 ± 1.0; severe: 2.8 ± 1.0), corresponding to a decrease of just 0.05 for a decrease in FFR of 0.1 (P < 0.001). CONCLUSIONS: MRR, unlike CFR, is minimally influenced by epicardial resistance, and thus should be considered the more specific index of microvascular function. This suggests that MRR can also reliably evaluate microvascular function in patients with significant epicardial disease.

Triglyceride glucose index and triglyceride HDL ratio as predictors of coronary artery stenosis in diabetic and non-diabetic patients.

BACKGROUND AND AIM: The current study investigated the association between triglyceride-glucose index (TyG) and triglyceride/HDL-C indices and coronary atherosclerosis extent in diabetic and non-diabetic patients. METHODS AND RESULTS: In this case-control study, 1538 individuals were classified into two groups: diabetic and non-diabetic subjects. Each group was further grouped as follows: (1) angiography+ (2) angiography-and (3) subjects without a history of cardiovascular diseases. The TyG and TG/HDL-C indices were compared between the subgroups of the diabetic (n = 407) and non-diabetic (n = 1131) groups. In both diabetic and non-diabetic patients, there was no significant association in TG/HDL-C; and diabetic subjects, angiography+ and angiography-groups had significantly higher TyG (p < 0.05). A high TyG index was associated with a higher risk of angiography+ (OR: 1.883 (1.410-2.514)). CONCLUSIONS: The TyG index, but not the TG/HDL-C, was an independent marker for predicting the severity of coronary stenosis in non-diabetic patients.

Clinical Value of Single-Projection Angiography-Derived FFR in Noninfarct-Related Artery.

BACKGROUND: The Murray law-based quantitative flow ratio (µFR) is an emerging technique that requires only 1 projection of coronary angiography with similar accuracy to quantitative flow ratio (QFR). However, it has not been validated for the evaluation of noninfarct-related artery (non-IRA) in acute myocardial infarction (AMI) settings. Therefore, our study aimed to evaluate the diagnostic accuracy of µFR and the safety of deferring non-IRA lesions with µFR >0.80 in the setting of AMI. METHODS: µFR and QFR were analyzed for non-IRA lesions of patients with AMI enrolled in the FRAME-AMI trial (Fractional Flow Reserve Versus Angiography-Guided Strategy for Management of Non-Infarction Related Artery Stenosis in Patients With Acute Myocardial Infarction), consisting of fractional flow reserve (FFR)-guided percutaneous coronary intervention and angiography-guided percutaneous coronary intervention groups. The diagnostic accuracy of µFR was compared with QFR and FFR. Patients were classified by the non-IRA µFR value of 0.80 as a cutoff value. The primary outcome was a vessel-oriented composite outcome, a composite of cardiac death, non-IRA-related myocardial infarction, and non-IRA-related repeat revascularization. RESULTS: µFR and QFR analyses were feasible in 443 patients (552 lesions). µFR showed acceptable correlation with FFR (R=0.777; P<0.001), comparable C-index with QFR to predict FFR ≤0.80 (µFR versus QFR: 0.926 versus 0.961, P=0.070), and shorter total analysis time (mean, 32.7 versus 186.9 s; P<0.001). Non-IRA with µFR >0.80 and deferred percutaneous coronary intervention had a significantly lower risk of vessel-oriented composite outcome than non-IRA with performed percutaneous coronary intervention (3.4% versus 10.5%; hazard ratio, 0.37 [95% CI, 0.14-0.99]; P=0.048). CONCLUSIONS: In patients with multivessel AMI, µFR of non-IRA showed acceptable diagnostic accuracy comparable to that of QFR to predict FFR ≤0.80. Deferred non-IRA with µFR >0.80 showed a lower risk of vessel-oriented composite outcome than revascularized non-IRA. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02715518.

Agreement of Fractional Flow Reserve Estimated by Computed Tomography With Invasively Measured Fractional Flow Reserve: A Systematic Review and Meta-Analysis.

BACKGROUND: Fractional flow reserve (FFR) is the ratio of blood pressure measured distal to a stenosis and pressure proximal to a stenosis. FFR can be estimated noninvasively using computed tomography (CT) although the usefulness of this technique remains controversial. This meta-analysis evaluated the agreement of FFR estimated by CT (FFR-CT) with invasively measured FFR. The study also evaluated the diagnostic accuracy of FFR-CT, defined as the ability of FFR-CT to classify lesions as hemodynamically significant (invasive FFR ≤0.8) or insignificant (invasive FFR >0.8). METHODS AND RESULTS: Forty-three studies reporting on 7291 blood vessels from 5236 patients were included. A moderate positive linear relationship between FFR-CT and invasively measured FFR was observed (Spearman correlation coefficient: 0.67). Agreement between the 2 measures increased as invasively measured FFR values approached 1. The overall diagnostic accuracy, sensitivity and specificity of FFR-CT were 82.2%, 80.9%, and 83.1%, respectively. Diagnostic accuracy of 90% could be demonstrated for FFR-CT values >0.90 and <0.49. The diagnostic accuracy of off-site tools was 79.4% and the diagnostic accuracy of on-site tools was 84.1%. CONCLUSIONS: The agreement between FFR-CT and invasive FFR is moderate although agreement is highest in vessels with FFR-CT >0.9. Diagnostic accuracy varies widely with FFR-CT value but is above 90% for FFR-CT values >0.90 and <0.49. Furthermore, on-site and off-site tools have similar performance. Ultimately, FFR-CT may be a useful adjunct to CT coronary angiography as a gatekeeper for invasive coronary angiogram.

Association between pre-treatment with statin and its inhibitory effect on the onset of coronary artery disease at the time of coronary computed tomography angiography: a new look at an old medication.

Coronary artery stenosis is often advanced by the time coronary computed tomography angiography (CCTA). Statins are the most important anti-lipidemic medication for improving the prognosis of coronary artery disease (CAD) patients. Although lipid-lowering therapy using statins appears to have been established as a method for preventing CAD, there remains the problem that CAD cannot be completely suppressed. In this study, we investigated whether pre-treatment with statin could significantly inhibit the onset of CAD when patients received CCTA for screening of CAD. The subjects were 1164 patients who underwent CCTA as screening for CAD. CAD was diagnosed when 50% or more coronary stenosis was present in the coronary arteries. Patient backgrounds were investigated by age, gender, body mass index, coronary risk factors [family history of cardiovascular diseases, smoking history, hypertension (HTN), diabetes mellitus (DM), dyslipidemia, chronic kidney disease (CKD) or metabolic sydrome] and medications. Patients were classified into two groups according to the presence or absence of statin pre-administration during CCTA [statin (-) group (n = 804) and (+) group (n = 360)]. Compared with the statin (-) group, the statin (+) group was significantly older and had higher rates of family history, HTN, and DM. The statin (+) group had a significantly higher % CAD than the statin (-) group. Serum levels of low-density lipoprotein cholesterol (LDL-C) were significantly lower in the statin (+) group than in the statin (-) group. There was no significant difference in either high-density lipoprotein cholesterol levels or triglyceride levels between the two groups. Age, male gender, HTN, DM and pre-treatment with statin were all associated with CAD (+) in all patients. In addition, factors that contributed to CAD (+) in the statin (-) group were age, male gender, and DM, and factors that contributed to CAD (+) in the statin (+) group were age, smoking, HTN and % maximum dose of statin. At the time of CCTA, the statin (+) group had a high rate of CAD and coronary artery stenosis progressed despite a reduction of LDL-C levels. To prevent the onset of CAD, in addition to strict control of other coronary risk factors (HTN etc.), further LDL cholesterol-lowering therapy may be necessary.

The correlation between subendocardial viability ratio and the degree of coronary artery stenosis in patients with coronary heart disease and its predictive value for the incidence of short-term cardiovascular events.

OBJECTIVES: This study aimed to analyze the ability of subendocardial viability ratio (SEVR) to predict the degree of coronary artery stenosis and the relationship between SEVR and the incidence of short-term cardiovascular endpoint events. METHOD: The indexes of 243 patients with chest pain were collected.. Binary logistic regression analyses were performed using the dichotomous outcome of high and non-high SYNTAX scores. Receiver operating characteristic curves were employed to comparatively analyze the diagnostic efficiencies of the indices and models. A survival analysis combined with the Cox regression analysis was performed using the Kaplan-Meier method to understand the relationship between the SEVR and the incidence of cardiovascular events within 1 year in patients with coronary heart disease (CHD). RESULTS: SEVR was significantly lower ( P  < 0.05) in the high-stenosis group than control and low-stenosis groups. The diagnostic efficacy of SEVR [area under the curve (AUC) = 0.861] was better than those of age (AUC = 0.745), ABI (AUC = 0.739), and AIx@HR75 (AUC = 0.659). The cutoff SEVR was 1.105. In patients with confirmed CHD who had been discharged from the hospital for 1 year, only SEVR affected survival outcomes (hazard ratio = 0.010; 95% confidence interval: 0.001-0.418; P  = 0.016). CONCLUSION: A significant decrease in SEVR predicted severe coronary artery stenosis, with a cutoff value of 1.105 and an accuracy of 0.861. In patients with CHD, the lower the SEVR, the higher was the rate of cardiovascular events at 1 year after hospital discharge.

A high level of uric acid is associated with long-term adverse cardiovascular outcomes in patients who received fractional flow reserve with coronary intermediate stenosis.

BACKGROUND AND AIMS: The role of fractional flow reserve (FFR) in coronary intermediate lesions is widely recommended by guidelines. The effect of uric acid (UA) on cardiovascular events is also well known. However, the relationship between UA and long-term cardiovascular outcomes in patients who received FFR with intermediate lesions remains unknown. METHODS AND RESULTS: We retrospectively included 428 patients who underwent both coronary angiography (CAG) and FFR. Participants were stratified into two groups based on the median UA. The primary endpoint was the composite of major adverse cardiovascular and cerebrovascular events (MACCEs), including repeat revascularization, nonfatal stroke, nonfatal myocardial infarction, and all-cause death. A Cox proportional hazards model was utilized to analyze the association between UA and the prevalence of MACCEs. During a median follow-up of 5.8 years, a higher MACCEs rate occurred in the high UA group compared to the low UA group (16.8% vs. 5.1%, p log-rank<0.01). Elevated UA was independently linked to a higher incidence of MACCEs, whether UA was treated as a categorical or continuous variable (hazard ratio [HR] 2.76, 95% confidence interval [CI] 1.27-6.03 or HR 1.01, 95% CI 1.01-1.02). The restricted cubic spline (RCS) analysis illustrated that the HR for MACCEs increased with increasing UA. CONCLUSION: The present study demonstrates that UA is associated with MACCEs risk and suggests that UA is a reliable predictor of long-term cardiovascular events in coronary intermediate stenosis patients.

Predictive value of plaque characteristics for identification of lesions causing ischemia.

BACKGROUND: Functional assessment using fractional flow reserve (FFR) and anatomical assessment using optical coherence tomography (OCT) are used in clinical practice for patients with intermediate coronary stenosis. Moreover, coronary computed tomography angiography (CTA) is a common noninvasive imaging technique for evaluating suspected coronary artery disease before being referred for angiography. This study aimed to investigate the association between FFR and plaque characteristics assessed using coronary CTA and OCT for intermediate coronary stenosis. METHODS: Based on a prospective multicenter registry, 159 patients having 339 coronary lesions with intermediate stenosis were included. All patients underwent coronary CTA before being referred for coronary angiography, and both FFR measurements and OCT examinations were performed during angiography. A stenotic lesion identified with FFR ≤0.80 was deemed diagnostic of an ischemia-causing lesion. The predictive value of plaque characteristics assessed using coronary CTA and OCT for identifying lesions causing ischemia was analyzed. RESULTS: Stenosis severity and plaque characteristics on coronary CTA and OCT differed between lesions that caused ischemia and those that did not. In multivariate analysis, low attenuation plaque on coronary CTA (odds ratio [OR]=2.78; P=0.038), thrombus (OR=5.13; P=0.042), plaque rupture (OR=3.25; P=0.017), and intimal vasculature on OCT (OR=2.57; P=0.012) were independent predictors of ischemic lesions. Increasing the number of these plaque characteristics offered incremental improvement in predicting the lesions causing ischemia. CONCLUSIONS: Comprehensive anatomical evaluation of coronary stenosis may provide additional supportive information for predicting the lesions causing ischemia.