Blood metabolomic fingerprint is distinct in healthy coronary and in stenosing or microvascular ischemic heart disease.

BACKGROUND: The endothelium is a key variable in the pathogenesis of atherosclerosis and its complications, particularly coronary artery disease (CAD). Current evidence suggests that the endothelial status can be regarded as an integrated index of individual atherogenic and anti-atherogenic properties, and that the interaction between circulating factors and the arterial wall might be critical for atherogenesis. In organism-level investigations, a functional view is provided by metabolomics, the study of the metabolic profile of small molecules. We sought to verify whether metabolomic analysis can reveal the presence of coronary microenvironment peculiarities associated with distinct manifestations of CAD. METHODS: Thirty-two coronary blood samples were analyzed using 1H-NMR-based metabolomics. Samples collected from patients with evidence of myocardial ischemia formed the case group, and were further divided into the stenotic-disease (SD) group (N = 13) and absence of stenosis (microvascular disease; "Micro") group (N = 8); specimens of patients presenting no evidence of ischemic heart disease (dilated cardiomyopathy, valvular diseases) constituted the control group (N = 11). RESULTS: Application of an orthogonal partial least squares discriminant analysis (OPLS-DA) model to the entire dataset clearly separated the samples into 3 groups, indicating 3 distinct metabolic fingerprints. Relative to control-group members, Micro patients showed a higher content of 2-hydroxybutirate, alanine, leucine, isoleucine, and N-acetyl groups and lower levels of creatine/phosphocreatine, creatinine, and glucose, whereas SD patients showed higher levels of 3-hydroxybutirate and acetate and a lower content of 2-hydroxybutirate. Moreover, relative to SD patients, Micro patients showed higher levels of 2-hydroxybutirate, alanine, leucine, and N-acetyl groups and lower levels of 3-hydroxybutirate and acetate. CONCLUSIONS: Specific coronary microenvironments are likely associated with distinct development and pathological expression of CAD.

Care quality monitoring of a ST-segment elevation myocardial infarction programme over a 5-year period.

AIMS: The aim of this study is to investigate the long-term impact of a prehospital ECG programme on treatment times for patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). METHODS: From January 2008 to December 2012, 213 STEMI patients transported by the Emergency Medical System (EMS) underwent primary PCI in our Hospital. The protocol included ECG tele-transmission, early activation of the cath lab and direct routing of the patient for primary PCI. Fifty-four patients referred by EMS in 2007, when ECG tele-transmission was unavailable, were used as controls. First diagnostic ECG-to-balloon time, door-to-balloon time and total ischemic time were collected for all patients. RESULTS: First diagnostic ECG-to-balloon time decreased from 125.5 min in 2007 to 104 min in the first year after implementation of the STEMI programme (2008). Successively, it declined to 81 min by the end of the study period (2012) (P < 0.0001). Door-to-balloon time decreased notably from 92.5 min in 2007 to 40.5 min by the end of the study period (p < 0.0001). Total ischemic time fell from 200 min in 2007 to 170 min in 2008 and it further declined to 163.5 min in 2012 (p < 0.042). CONCLUSIONS: We report progressive improvements in times to treatment over a 5-year period in a STEMI program for patients referred by the EMS. The importance of data collection and monitoring is highlighted by our results.

[The network for acute coronary syndromes in the metropolitan area of Cagliari (Italy): management of ST-elevation myocardial infarction, reperfusion time, and adherence to guidelines]. / La rete per l'emergenza coronarica nell'Area Vasta di Cagliari: gestione dell'infarto miocardico acuto con sopraslivellamento del tratto ST, analisi dei tempi di riperfusione e aderenza alle linee guida.

BACKGROUND: An integrated network for the management of acute ST-elevation myocardial infarction (STEMI) allows a pre-hospital diagnosis and facilitates the best strategy to provide the most effective reperfusion therapy. This study aims to assess the network impact on timing and mode of reperfusion in the metropolitan area of Cagliari. METHODS: From January 1, 2008 to December 31, 2010 all patients affected by STEMI with symptom onset <12h were enrolled. We evaluated modality of hospital access, reperfusion therapies, and time for avoidable delay. The first medical contact-to-balloon time (FMC-to-balloon) was compared between patients without ECG transmission (No-ECG group) and those with ECG transmission and direct transport to the cath-lab (Cath-Lab-ECG group) or the emergency room/intensive cardiac care unit (ER/ICCU-ECG group). RESULTS: Out of 622 patients enrolled, 324 (52.1%) arrived to hospital by emergency medical systems. In this group a pre-hospital diagnosis was made in 79.3% of cases (n = 257); among them, 138 patients (53.7%) had a direct access to cath-lab, 99 to ICCU (38.5%), and 20 (7.8%) to ER. In the whole study population an urgent coronary angiography was performed in 612 patients (98.4%) and a primary percutaneous coronary intervention (p-PCI) in 589 (96.2%). In the Cath-Lab-ECG group the FMC-to-balloon was 89 ± 29 min (median 87 min, interquartile range 72-100), significantly lower than in the ER/ICCU-ECG group [122 ± 39 min (115 min)] and the No-ECG group [150 ± 54 min (139 min)] (p<0.01). A FMC-to-balloon ≤90 min was achieved in 66.4% of Cath-Lab-ECG patients, 22.1% of ER/ICCU-ECG patients, and 8.3% of No-ECG patients (Cath-Lab-ECG vs ER/ICCU-ECG, p<0.01). CONCLUSIONS: Our results show that an integrated network provides a pre-hospital diagnosis in the majority of STEMI. However, only a direct transport to the cath-lab allows to achieve a FMC-to-balloon ≤90 min in a large proportion of patients. Out of this condition, adherence to guideline-recommended time of ≤90 min is significantly lower.

Early noninvasive evaluation of coronary flow reserve after angioplasty in the left anterior descending coronary artery identifies patients at high risk of restenosis at follow-up.

BACKGROUND: Coronary restenosis is the most important clinical limitation after percutaneous coronary intervention (PCI), and coronary flow reserve (CFR) is reduced in the presence of significant coronary stenosis. This study evaluated whether detection of early reduction of Doppler echocardiographically derived CFR in the left anterior descending coronary artery can identify patients at high risk for developing restenosis after successful PCI. METHODS: Doppler echocardiographically derived CFR was studied in 124 consecutive patients at 1-month and 6-month follow-up after PCI in the left anterior descending coronary artery, together with coronary angiography. RESULTS: Restenosis was detected in 39 angiographic examinations (group A) and no coronary restenosis in the remaining 85 (group B) at 6 months. At 1 month, CFR was reduced in group A compared with group B (P < .0001), and a significant reduction of CFR in group A (P < .0001) but not in group B (P = .89) was detected at 6 months. CFR ≤ 2.5 at 1 month was 67% sensitive and 87% specific for predicting significant restenosis, with positive and negative predictive values of 67% and 87%, respectively. CONCLUSIONS: CFR ≤ 2.5 detected 1 month after PCI in the left anterior descending coronary artery has the potential to identify patients at higher risk for developing coronary restenosis and indicates the need for close clinical follow-up.

Detection, location, and severity assessment of left anterior descending coronary artery stenoses by means of contrast-enhanced transthoracic harmonic echo Doppler.

AIMS: Contrast-enhanced second harmonic Doppler (ED) is a new ultrasound modality that increases the feasibility of recording blood flow velocity (BFV) in the left anterior descending coronary artery (LAD) using a transthoracic approach. Blood flow velocity convective acceleration is a reliable marker of coronary stenosis and can be used to assess the percentage area reduction at the stenosis site by applying the continuity equation. To detect, locate, and assess the severity of significant stenosis throughout the LAD by means of an ED recording of BFV acceleration at the stenosis site. METHODS AND RESULTS: Fifty-three consecutive patients undergoing coronary angiography (CA) underwent a colour-guided pulsed-wave ED recording of BFV in the proximal/mid and distal portions of the LAD, and maximal and reference BFV was obtained in each of the two arterial segments. Maximal velocity was much higher in the diseased segments (>or=50% lumen narrowing) than in the normal segments (143 +/- 84 vs. 38 +/- 20 cm/s; P < 0.001); as the reference velocity was similar (37 +/- 13 vs. 31 +/- 12; P = 0.03), the percentage increase in velocity was also higher (290 +/- 233 vs. 20 +/- 37%; P < 0.001). Using a cut-off value of an 82% increase in velocity, sensitivity and specificity vs. CA was, respectively, 86 and 95%. The reduction in the percentage area of stenosis calculated using the continuity equation agreed with that determined by means of quantitative CA (r = 0.7). CONCLUSION: Blood flow velocity evaluation in the LAD by means of transthoracic ED is feasible and reliable in detecting, locating, and assessing the severity of LAD stenosis.

Detection of coronary restenosis after coronary angioplasty by contrast-enhanced transthoracic echocardiographic Doppler assessment of coronary flow velocity reserve.

OBJECTIVES: This study sought to evaluate the diagnostic potential of contrast-enhanced transthoracic echocardiography (CE-TTE) during adenosine infusion, a noninvasive method for evaluating coronary flow reserve (CFR), in detecting restenosis after successful percutaneous transluminal coronary angioplasty (PTCA). BACKGROUND: Restenosis is the most important limitation of PTCA, and CFR can be impaired in patients with angiographically documented significant coronary stenosis. METHODS: We performed 6 +/- 2 months of follow-up of 53 patients after successful elective PTCA in the left anterior descending coronary artery (LAD). Coronary angiography was performed at the end of the planned follow-up period or even before, if clinically indicated. Thus, of the 53 patients, a total of 63 angiographic studies were performed; CE-TTE assessment of CFR was achieved before each of the 63 angiographic studies. RESULTS: Coronary angiography revealed the presence of restenosis (defined as >50% stenosis at a previous PTCA site) in 32 angiographic examinations (group A) and no coronary restenosis in the remaining 31 examinations (group B). Coronary flow reserve was significantly reduced in group A compared with group B (1.65 +/- 0.5 vs. 3.17 +/- 0.8, p < or = 0.001). A noninvasive CFR value < or = 2 was 93% specific and 78% sensitive for detecting significant restenosis, with positive and negative diagnostic accuracies of 92% and 80%, respectively. CONCLUSIONS: Noninvasive CFR assessment by CE-TTE is an accurate method of monitoring significant restenosis in the LAD when following up patients submitted to elective PTCA.