Association between fractional flow reserve, instantaneous wave-free ratio and dobutamine stress echocardiography in patients with stable coronary artery disease.

AIMS: The association between fractional flow reserve (FFR) and dobutamine stress echocardiography (DSE) in real-world stable angina patients is scant and controversial whereas no such comparison exists with instantaneous wave-free ratio (iFR). The current retrospective study aimed to investigate the associations among these modalities in patients with stable coronary artery disease (CAD) and intermediate coronary lesions. METHODS AND RESULTS: We studied 62 consecutive stable angina patients who underwent DSE and subsequently coronary angiography with FFR (in all 62) and iFR (in 46/62 patients) assessment of intermediate single-vessel lesions between 2014 and 2015. Using receiver operating characteristic (ROC) curves we sought to identify the optimal FFR and iFR cut-off points with the highest discriminative power to predict the DSE result. The kappa coefficient was used to assess the agreement between FFR, iFR and DSE. The mean age of the study cohort was 63.5±12 years and 35 (56.5%) were males. Thirteen (21%) lesions were adjudicated as causing reversible ischaemia on DSE. Using ROC (FFR predicting DSE result), the area under the curve was 0.952 (95% CI: 0.902 to 1), whereas for iFR it was 0.743 (95% CI: 0.560 to 0.927), pAUC comparison=0.03. The optimal FFR cut-off point predicting positive DSE was 0.80. There was strong agreement between DSE and FFR (kappa 0.682, p<0.001). There was only modest agreement between iFR and DSE (kappa 0.258, p=0.068) using a cut-off value of 0.9. CONCLUSIONS: In patients referred for evaluation of stable CAD, there was good agreement between DSE and FFR (87%) but less so with iFR (71.7%).

An unusual pattern of three major components of the cardiovascular system: multimodality imaging and review of the literature.

INTRODUCTION: Coronary artery anomalies are found in 0.4% to 1.4% of patients who undergo coronary angiography. Anomalous origin of left coronary artery from the right sinus of Valsava is the rarest, with a reported prevalence of 0.02 -0.03% according to angiographic studies. CASE PRESENTATION: We present the rare case of a 42-year-old-man suffering from stable angina with unusual development of 3 major components of the cardiovascular system Coronary angiography revealed an anomalous origin of the left coronary artery from the ostium of the right coronary artery. Magnetic resonance angiography depicted an anomalous origin of the left common carotid artery from the innominate artery and an aneurysm of descending thoracic aorta. Coronary computed tomography angiography revealed the course of left coronary artery between aortic root and conus arteriosus at the level of the right ventricular outflow tract. In this report we attempt to highlight the rarity of this vascular anatomy. CONCLUSION: Anomalous origins of the coronary arteries are rare, but may cause myocardial ischemia and sudden death. Thus, their reliable identification is a matter of paramount importance possibly evaluating the effects of therapeutic intervention. Newer imaging modalities improve the illumination of vascular system anatomy, shedding light to diagnostic dilemmas that come up in daily medical practice.

Pathophysiology of resistant hypertension: the role of sympathetic nervous system.

Resistant hypertension (RH) is a powerful risk factor for cardiovascular morbidity and mortality. Among the characteristics of patients with RH, obesity, obstructive sleep apnea, and aldosterone excess are covering a great area of the mosaic of RH phenotype. Increased sympathetic nervous system (SNS) activity is present in all these underlying conditions, supporting its crucial role in the pathophysiology of antihypertensive treatment resistance. Current clinical and experimental knowledge points towards an impact of several factors on SNS activation, namely, insulin resistance, adipokines, endothelial dysfunction, cyclic intermittent hypoxaemia, aldosterone effects on central nervous system, chemoreceptors, and baroreceptors dysregulation. The further investigation and understanding of the mechanisms leading to SNS activation could reveal novel therapeutic targets and expand our treatment options in the challenging management of RH.