Baseline coronary artery stenosis severity is an independent predictor of subsequent poor sleep quality in patients with acute coronary syndrome.

AIM: To investigate the relationship between coronary artery lesion severity determined using the baseline SYNTAX score and sleep problems that might occur after discharge determined using the Pittsburgh Sleep Quality Index (PSQI). METHODS: This prospective study included patients with first acute coronary syndrome (ACS) who underwent percutaneous coronary angiography between February 2019 and August 2019. The severity of coronary artery stenosis was classified according to coronary angiography and SYNTAX scores. Patients were grouped as those with a SYNTAX score of ≤22 and >22. Sleep quality after discharge was classified according to the PSQI. PSQI ≤5 represented good sleep quality, and PSQI >5 represented poor sleep quality. Univariate and multivariate logistic regression was used to investigate the relationship between sleep quality and coronary artery stenosis severity. RESULTS: A total of 424 patients were included in the study. Of these, 294 (69.34%) had a SYNTAX score of ≤22 and 130 (30.66%) had a SYNTAX score of >22. The mean age of all patients was 60.37 ±â€…12.23 years, 59.69 ±â€…11.85 years in the SYNTAX ≤22 groups and 61.90 ±â€…12.98 years in the SYNTAX >22 group (P = 0.086). The majority (78.54%) of the patients were male and there was no significant difference between the SYNTAX ≤22 group and the SYNTAX >22 group in terms of sex distribution (P = 0.383). According to the univariate logistic regression analysis, age (P = 0.014), diabetes (P = 0.027), left ventricular ejection fraction (P = 0.001), estimated glomerular filtration rate (P = 0.039), creatine kinase MB (P = 0.040) and SYNTAX scores (P < 0.001) were significantly associated with high PSQI global scores (>5). However, according to the multivariate logistic regression analysis results, high (>22) SYNTAX scores were the only factor independently associated with the high (>5) PSQI global scores [odds ratio, 3.477; 95% confidence interval (CI), (2.190-5.522); P < 0.001]. Complete revascularization group had significantly higher sleep latency and sleep duration time, sleep efficiency and the percentage of patients with PSQI global score of ≤5 than the incomplete revascularization group (P < 0.001 for all). CONCLUSION: Among patients with ACS, those with high SYNTAX scores should be monitored more carefully for sleep disorders that may occur later.

The additive effect of metabolic syndrome on left ventricular impairment in patients with obstructive coronary artery disease assessed by 3.0 T cardiac magnetic resonance feature tracking.

BACKGROUND: Metabolic syndrome (MetS) can increase the risk of morbidity and mortality of cardiovascular disease and obstructive coronary artery disease (OCAD), which usually have a poor prognosis. This study aimed to explore the impact of MetS on left ventricular (LV) deformation and function in OCAD patients and investigate the independent factors of impaired LV function and deformation. MATERIALS AND METHODS: A total of 121 patients with OCAD and 52 sex- and age-matched controls who underwent cardiac magnetic resonance scanning were enrolled in the study. All OCAD patients were divided into two groups: OCAD with MetS [OCAD(MetS+), n = 83] and OCAD without MetS [OCAD(MetS-), n = 38]. LV functional and global strain parameters were measured and compared among the three groups. Multivariable linear regression analyses were constructed to investigate the independent factors of LV impairment in OCAD patients. Logistic regression analysis and receiver operating characteristic (ROC) curve analysis were performed to test the prediction efficiency of MetS for LV impairment. RESULTS: From controls to the OCAD(MetS-) group to the OCAD(MetS+) group, LV mass (LVM) increased, and LV global function index (LVGFI) and LV global longitudinal peak strain (GLPS) decreased (all p < 0.05). Compared with the OCAD(MetS-) group, the LV GLPS declined significantly (p = 0.027), the LVM increased (p = 0.006), and the LVGFI decreased (p = 0.043) in the OCAD(MetS+) group. After adjustment for covariates in OCAD patients, MetS was an independent factor of decreased LV GLPS (ß = - 0.211, p = 0.002) and increased LVM (ß = 0.221, p = 0.003). The logistic multivariable regression analysis and ROC analysis showed that combined MetS improved the efficiency of predicting LV GLPS reduction (AUC = 0.88) and LVM (AUC = 0.89) increase. CONCLUSIONS: MetS aggravated the damage of LV deformation and function in OCAD patients and was independently associated with LV deformation and impaired LV strain. Additionally, MetS increased the prediction efficiency of increased LVM and decreased LV GLPS. Early detection and intervention of MetS in patients with OCAD is of great significance.

Diagnostic performance of deep learning and computational fluid dynamics-based instantaneous wave-free ratio derived from computed tomography angiography.

BACKGROUND AND OBJECTIVES: Both fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are widely used to evaluate ischemia-causing coronary lesions. A new method of CT-iFR, namely AccuiFRct, for calculating iFR based on deep learning and computational fluid dynamics (CFD) using coronary computed tomography angiography (CCTA) has been proposed. In this study, the diagnostic performance of AccuiFRct was thoroughly assessed using iFR as the reference standard. METHODS: Data of a total of 36 consecutive patients with 36 vessels from a single-center who underwent CCTA, invasive FFR, and iFR were retrospectively analyzed. The CT-derived iFR values were computed using a novel deep learning and CFD-based model. RESULTS: Mean values of FFR and iFR were 0.80 ± 0.10 and 0.91 ± 0.06, respectively. AccuiFRct was well correlated with FFR and iFR (correlation coefficients, 0.67 and 0.68, respectively). The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of AccuiFRct ≤ 0.89 for predicting FFR ≤ 0.80 were 78%, 73%, 81%, 73%, and 81%, respectively. Those of AccuiFRct ≤ 0.89 for predicting iFR ≤ 0.89 were 81%, 73%, 86%, 79%, and 82%, respectively. AccuiFRct showed a similar discriminant function when FFR or iFR were used as reference standards. CONCLUSION: AccuiFRct could be a promising noninvasive tool for detection of ischemia-causing coronary stenosis, as well as facilitating in making reliable clinical decisions.

Preprocedural transthoracic Doppler echocardiography to identify stenosis associated with increased coronary flow after revascularisation.

The benefit of percutaneous coronary intervention (PCI) has been reported to be associated with functional stenosis severity defined by fractional flow reserve (FFR). This study aimed to investigate the predictive ability of preprocedural transthoracic Doppler echocardiography (TDE) for increased coronary flow. A total of 50 left anterior descending arteries (LAD) that underwent TDE examinations were analysed. Hyperaemic LAD diastolic peak velocity (hDPV) was used as a surrogate of volumetric coronary flow. The increase in coronary flow was evaluated by the metric of % hDPV-increase defined by 100× (post-PCI hDPV-pre-PCI hDPV)/pre-PCI hDPV. The two groups divided by the median value of % hDPV-increase were compared, and the determinants of a significant coronary flow increase defined as more than the median % hDPV-increase were explored. After PCI, FFR values improved in all cases. hDPV significantly increased from 53.0 to 76.0 mm/s (P < 0.01) and the median % hDPV-increase was 45%, while hDPV decreased in 10 patients. On multivariable analysis, pre-PCI FFR and hDPV were independent predictors of a significant coronary flow increase. Preprocedural TDE-derived hDPV provided significant improvement of identification of lesions that benefit from revascularisation with respect to significant coronary flow increase.

Effect of Calcification Based on Computer-Aided System on CT-Fractional Flow Reserve in Diagnosis of Coronary Artery Lesion.

This study was to analyze the diagnostic value of coronary computed tomography angiography (CCTA) and fractional flow reserve (FFR) based on computer-aided diagnosis (CAD) system for coronary lesions and the possible impact of calcification. 80 patients who underwent CCTA and FFR examination in hospital were selected as the subjects. The FFR value of 0.8 was used as the dividing line and divided into the ischemic group (FFR ≤ 0.8) and nonischemic group (FFR > 0.8). The basic data and imaging characteristics of patients were analyzed. The maximum diameter stenosis rate (MDS %), maximum area stenosis rate (MAS %), and napkin ring sign (NRS) in the ischemic group were significantly lower than those in the nonischemic group (P < 0.05). Remodeling index (RI) and eccentric index (EI) compared with the nonischemic group had no significant difference (P > 0.05). The total plaque volume (TPV), total plaque burden (TPB), calcified plaque volume (CPV), lipid plaque volume (LPV), and lipid plaque burden (LPB) in the ischemic group were significantly different from those in the non-ischemic group (P < 0.05). MAS % had the largest area under curve (AUC) for the diagnosis of coronary myocardial ischemia (0.74), followed by MDS % (0.69) and LPV (0.68). CT-FFR had high diagnostic sensitivity, specificity, accuracy, truncation value, and AUC area data for patients in the ischemic group and nonischemic group. The diagnostic sensitivity, specificity, accuracy, cutoff value, and AUC area data of CT-FFR were higher in the ischemic group (89.93%, 92.07%, 95.84%, 60.51%, 0.932) and nonischemic group (93.75%, 90.88%, 96.24%, 58.22%, 0.944), but there were no significant differences between the two groups (P > 0.05). In summary, CT-FFR based on CAD system has high accuracy in evaluating myocardial ischemia caused by coronary artery stenosis, and within a certain range of calcification scores, calcification does not affect the diagnostic accuracy of CT-FFR.

Predictors of fractional flow reserve/instantaneous wave-free ratio discordance: impact of tailored diagnostic cut-offs on clinical outcomes of deferred lesions.

BACKGROUND: Patient-related and lesion-related factors may influence instantaneous wave-free ratio (iFR)/fractional flow reserve (FFR) concordance, potentially affecting the safety of revascularization deferral. METHODS: Consecutive patients with at least an intermediate coronary stenosis evaluated by both iFR and FFR were retrospectively enrolled. The agreement between iFR and FFR at their diagnostic cut-offs (FFR 0.80, iFR 0.89) was assessed. Predictors of discordance were assessed using multivariate analyses. Tailored iFR cut-offs according to predictors of discordance best matching an FFR of 0.80 were identified. The impact of reclassification according to tailored iFR cut-offs on major cardiovascular events (MACE: cardiovascular death, myocardial infarction or target-lesion revascularization) among deferred lesions was investigated. RESULTS: Two hundred and ninety-nine intermediate coronary stenosis [FFR 0.84 (0.78-0.89), iFR 0.91 (0.87-0.95), 202 left main/left anterior descending (LM/LAD) vessels, 67.6%] of 260 patients were studied. Discordance rate was 23.4% (n = 70, 10.7% iFR-negative discordant, 12.7% iFR-positive discordant). Predictors of discordance were LM/LAD disease, multivessel disease, non-ST-elevation myocardial infarction, smoking, reduced eGFR and hypertension. Lesion reclassification with tailored iFR cut-offs based on patient-level predictors carried no prognostic value among deferred lesions. Reclassification according to lesion location, which was entirely driven by LM/LAD lesions (iFR cut-offs: 0.93 for LM/LAD, 0.89 for non-LM/LAD), identified increased MACE among lesions deferred based on a negative FFR, between patients with a positive as compared with a negative iFR (19.4 vs. 6.1%, P = 0.044), whereas the same association was not observed with the conventional 0.89 iFR cut-off (15 vs. 8.6%, P = 0.303). CONCLUSION: Tailored vessel-based iFR cut-offs carry prognostic value among FFR-negative lesions, suggesting that a one-size-fit-all iFR cut-off might be clinically unsatisfactory.

Reliability of Fractional Flow Reserve and Instantaneous Wave-Free Ratio in Assessing Intermediate Coronary Stenosis in Patients With Atrial Fibrillation.

Despite the current use of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) for guiding revascularization in atrial fibrillation (AF), there is a lack of studies evaluating their reliability in this particular population. This retrospective study aimed to investigate the reliability of FFR and iFR in patients with AF. This retrospective study included all patients with AF undergoing FFR measurements (n = 45 vessels from 36 patients) at Brugmann University Hospital, Brussels, Belgium, between 2012 and 2020 or iFR (n = 18 vessels from 13 patients) and a corresponding number of patients with sinus rhythm (SR) randomly selected from the same period, benefiting from iFR (n = 20 vessels from 17 patients) or FFR (n = 50 vessels from 37 patients). Our main findings indicate that there is an increased beat-to-beat variability of individual iFR measures in patients with AF, compared with SR. In addition, the reproducibility of iFR on test-retest is low in patients with AF, leading to increased lesion reclassification (53.8% of lesions reclassified on 2 consecutive iFR measurements in AF vs 6.6% lesions reclassified in SR, p <0.05). In contrast, FFR seems to be more robust in evaluating coronary lesions in AF in terms of equivalent variability, reproducibility, and lesion reclassification observed in the SR population. In conclusion, this is the first study to evaluate the reliability of iFR and FFR in AF. Our findings raise caution in using iFR to guide revascularization in patients with AF, whereas FFR seems to be more robust in this population.

Predicting haemodynamic significance of coronary stenosis with radiomics-based pericoronary adipose tissue characteristics.

AIM: To investigate the diagnostic performance of the radiomics features of pericoronary adipose tissue (PCAT) in determining haemodynamically significant coronary artery stenosis as evaluated by fractional flow reserve (FFR). MATERIALS AND METHODS: A total of 92 patients with clinically suspected coronary artery disease who underwent coronary computed tomography (CT) angiography (CCTA), invasive coronary angiography (ICA), and FFR examination within 1 month were included retrospectively, and 121 lesions were randomly assigned to the training and testing set. Based on manual segmentation of PCAT, 1,116 radiomics features were computed. After radiomics robustness assessment and feature selection, radiomics models were established using the different machine-learning algorithms. The area under the receiver operating characteristic (ROC) curve (AUC) and net reclassification index (NRI) were analysed to compare the discrimination and reclassification abilities of radiomics models. RESULTS: Two radiomics features were selected after exclusions, and both were significantly higher in coronary arteries with FFR ≤0.8 than those with FFR >0.8. ROC analysis showed that the combination of CCTA and decision tree radiomics model achieved significantly higher diagnostic performance (AUC: 0.812) than CCTA alone (AUC: 0.599, p=0.015). Furthermore, the NRI of the combined model was 0.820 and 0.775 in the training and testing sets, respectively, suggesting the radiomics features of PCAT had were effective in classifying the haemodynamic significance of coronary stenosis. CONCLUSIONS: Adding PCAT radiomics features to CCTA enabled identification of haemodynamically significant coronary artery stenosis.

Aumento do trabalho miocárdico desperdiçado como indicador de lesão coronariana significativa / Increased wasted myocardial work as an indicator of significant coronary lesion

Introdução: A avaliação dos índices de trabalho miocárdico global em condições basais pode ser útil para a estratificação clínica de pacientes com suspeita de obstrução coronariana. Objetivo: Correlacionar o valor do índice de trabalho miocárdico global e a presença de lesões obstrutivas coronarianas significativas. Método: Estudo transversal, com pacientes encaminhados para cinecoronarioangiografia eletiva. Foi realizado ecocardiograma com obtenção das medidas para cálculo do valor do trabalho miocárdico, sendo avaliada a presença de lesões obstrutivas coronarianas significativas à cinecoronarioangiografia. Resultados: A amostra foi composta de 30 pacientes, com a idade média de 64,2±12,8 anos, sendo a maioria do sexo masculino (63,3%), dos quais 68,4% apresentaram lesões obstrutivas coronarianas significativas. O índice de trabalho miocárdico global foi de 1.876mmHg%±253,8 no grupo com lesões obstrutivas coronarianas significativas e de 2.054,2mmHg%±417,3 naqueles sem lesões significativas (p=0,089). O trabalho miocárdio construtivo global nos pacientes sem lesões obstrutivas coronarianas significativas foi maior (2.329,3mmHg%±462,9) do que naqueles com lesões obstrutivas coronarianas significativas (2.109,5mmHg%±332,3; p=0,064). O trabalho miocárdio desperdiçado global foi maior nos pacientes com lesões obstrutivas coronarianas significativas (103,7mmHg%±47,1 versus 68,3mmHg%±33,8; p=0,038). O ponto de corte de 115mmHg% foi aquele com a melhor área sob a curva (0,625), com sensibilidade de 83,3%. Conclusão: O aumento do trabalho miocárdio desperdiçado global se correlacionou com a presença de lesões obstrutivas coronarianas significativas em nossa amostra.(AU)

Introduction: The assessment of global myocardial work indices under baseline conditions may be useful for the clinical stratification of patients with suspected coronary obstruction. Objective: To correlate the value of global myocardial work indices and the presence of significant obstructive coronary lesions. Method: Cross-sectional study, with patients referred for elective coronary angiography. An echocardiogram was performed to obtain measurements to calculate the value of myocardial work and evaluated the presence or presence of significant obstructive coronary lesions at coronary angiography. Results: The sample consisted of 30 patients, with a mean age of 64.2±12.8 years, the majority being male (63.3%), of which 68.4% had significant obstructive coronary lesions. The global myocardial work indices was 1,876mmHg%±253.8 in the group with significant obstructive coronary lesions and 2,054.2mmHg%±417.3 in those without significant lesions (p=0.089). Global constructive myocardial work in patients without significant obstructive coronary lesions was higher (2,329.3mmHg%±462.9) than in those with significant obstructive coronary lesions (2,109.5mmHg%±332.3; p=0.064). Global wasted myocardial work was higher in patients with significant obstructive coronary lesions (103.7mmHg%±47.1 versus 68.3mmHg%±33.8; p=0.038). The cutoff point of 115 mmHg% was the one with the best area under the curve (0.625), with a sensitivity of 83.3%. Conclusion: The increase in global wasted myocardial work correlated with the presence of significant obstructive coronary lesions in our sample. (AU)

Apolipoprotein B/A1 Ratio Is Associated with Severity of Coronary Artery Stenosis in CAD Patients but Not in Non-CAD Patients Undergoing Percutaneous Coronary Intervention.

BACKGROUND AND AIMS: Lipid metabolism plays important roles in atherosclerosis. Several studies have found that lipoprotein is associated with coronary artery disease (CAD) and hyperlipidemia. Although the roles of the apolipoprotein B/A1 ratio (ApoB/A1) were originally thought to be atherosclerotic, few studies have focused on the specific relationship between ApoB/A1 and severity of coronary artery stenosis with or without the presence of CAD. METHODS: A total of 6956 consecutive patients aged 21-98 years with suspected CAD who had undergone coronary angiography were enrolled. The severity of coronary lesions was evaluated using the Gensini score (GS). The relationships between ApoB/A1 and severity of coronary artery stenosis were evaluated. RESULTS: A total of 1795 non-CAD patients and 5161 CAD patients were included in the observational analysis. Patients with CAD had higher ApoB/A1 than individuals without CAD (0.67 (0.53-0.82) vs. 0.61 (0.49-0.75), p < 0.001). In CAD patients, the higher the ApoB/A1 was, the higher the proportion of patients with MI, triple-vessel lesions, and higher Gensini scores. ApoB/A1 was significantly positively correlated with HbA1c and Gensini scores in CAD patients but not in non-CAD patients (all p < 0.001). Logistic analyses showed that ApoB/A1 could be a risk factor for multivessel disease (OR: 2.768, 95% CI: 1.868-4.103, p < 0.001). ApoB/A1 was found to be significantly positively correlated with the Gensini score in CAD patients. CONCLUSIONS: ApoB/A1 is highly associated with the presence and severity of coronary artery stenosis in patients with CAD but not in non-CAD patients.

Numerical modelling of blood rheology and platelet activation through a stenosed left coronary artery bifurcation.

Coronary bifurcations are prone to atherosclerotic plaque growth, experiencing regions of reduced wall shear stress (WSS) and increased platelet adhesion. This study compares effects across different rheological approaches on hemodynamics, combined with a shear stress exposure history model of platelets within a stenosed porcine bifurcation. Simulations used both single/multiphase blood models to determine which approach best predicts phenomena associated with atherosclerosis and atherothrombosis. A novel Lagrangian platelet tracking model was used to evaluate residence time and shear history of platelets indicating likely regions of thrombus formation. Results show a decrease in area of regions with pathologically low time-averaged WSS with the use of multiphase models, particularly in a stenotic bifurcation. Significant non-Newtonian effects were observed due to low-shear and varying hematocrit levels found on the outer walls of the bifurcation and distal to the stenosis. Platelet residence time increased 11% in the stenosed artery, with exposure times to low-shear sufficient for red blood cell aggregation (>1.5 s). increasing the risk of thrombosis. This shows stenotic artery hemodynamics are inherently non-Newtonian and multiphase, with variations in hematocrit (0.163-0.617) and elevated vorticity distal to stenosis (+15%) impairing the function of the endothelium via reduced time-averaged WSS regions, rheological properties and platelet activation/adhesion.

Diagnostic Performance of Dynamic Myocardial Perfusion Imaging Using Dual-Source Computed Tomography.

BACKGROUND: Single-center studies indicated a high diagnostic accuracy of dynamic computed tomography perfusion (CTP) imaging in the diagnosis of coronary artery disease (CAD). OBJECTIVES: This prospective multicenter study determined the diagnostic performance of combined coronary computed tomography angiography (CTA) and CTP for detecting hemodynamically significant CAD defined by invasive coronary angiography (ICA) with fractional flow reserve (FFR). METHODS: Seven centers enrolled 174 patients with suspected or known CAD who were clinically referred for ICA. CTA and dynamic CTP were performed using dual-source CT before ICA. FFR was done as part of ICA in the case of 26% to 90% coronary diameter stenosis. Hemodynamically significant stenosis was defined as FFR of <0.8 or >90% stenosis on ICA. RESULTS: The study protocol was completed in 157 participants, and hemodynamically significant stenosis was detected in 76 of 157 patients (48%) and 112 of 442 vessels (25%). According to receiver-operating characteristic curve analysis, adding dynamic CTP to CTA significantly increased the area under the curve from 0.65 (95% CI: 0.57-0.72) to 0.74 (95% CI: 0.66-0.81; P = 0.011) on the patient level, with decreased sensitivity (93% vs 72%; P < 0.001), improved specificity (36% vs 75%; P < 0.001), and improved overall accuracy (64% vs 74%; P < 0.001). CONCLUSIONS: In this prospective multicenter study on dynamic CTP, the combination of anatomic assessment with coronary CTA and functional evaluation with dynamic CTP allowed more accurate identification of hemodynamically significant CAD compared with CTA alone. However, the clinical significance of this approach needs to be further investigated, including its usefulness in improving prognosis. (Assessment of Myocardial Perfusion Linked to Infarction and Fibrosis Explored With Dual-Source CT [AMPLIFiED]; UMIN000016353).

An improved reduced-order model for pressure drop across arterial stenoses.

Quantification of pressure drop across stenotic arteries is a major element in the functional assessment of occlusive arterial disease. Accurate estimation of the pressure drop with a numerical model allows the calculation of Fractional Flow Reserve (FFR), which is a haemodynamic index employed for guiding coronary revascularisation. Its non-invasive evaluation would contribute to safer and cost-effective diseases management. In this work, we propose a new formulation of a reduced-order model of trans-stenotic pressure drop, based on a consistent theoretical analysis of the Navier-Stokes equation. The new formulation features a novel term that characterises the contribution of turbulence effect to pressure loss. Results from three-dimensional computational fluid dynamics (CFD) showed that the proposed model produces predictions that are significantly more accurate than the existing reduced-order models, for large and small symmetric and eccentric stenoses, covering mild to severe area reductions. FFR calculations based on the proposed model produced zero classification error for three classes comprising positive (≤ 0.75), negative (≥ 0.8) and intermediate (0.75 - 0.8) classes.

Clinical Efficacy of Intracoronary Papaverine After Nicorandil Administration for Safe and Optimal Fractional Flow Reserve Measurement.

Fractional flow reserve (FFR) is considered the standard for assessment of the physiological significance of coronary artery stenosis. Intracoronary papaverine (PAP) is the most potent vasodilator used for the achievement of maximal hyperemia. However, its use can provoke ventricular tachycardia (VT) due to excessive QT prolongation. We evaluated the clinical efficacy and safety of the administration of PAP after nicorandil (NIC), a potassium channel opener that prevents VT, for optimal FFR measurement.A total of 127 patients with 178 stenoses were enrolled. The FFR values were measured using NIC (NIC-FFR) and PAP (PAP-FFR). We administered PAP following NIC (NIC-PAP). Changes in the FFR and electrogram parameters (baseline versus NIC versus PAP) were assessed and the incidence of arrhythmias after PAP was evaluated. In addition, we analyzed another 41 patients with 51 stenoses by assessing the FFR using PAP before NIC (PAP-NIC). After propensity score matching, the electrogram parameters between 2 groups were compared.The mean PAP-FFR was significantly lower than the mean NIC-FFR (0.82 ± 0.11 versus 0.81 ± 0.11, P < 0.05). The mean baseline-QTc, NIC-QTc, and PAP-QTc values were 425 ± 37 ms1/2, 424 ± 41 ms1/2, and 483 ± 54 ms1/2, respectively. VT occurred in only 1 patient (0.6%). Although PAP induced QTc prolongation (P < 0.05), the PAP-QTc duration was significantly shorter in NIC-PAP compared to PAP-NIC (P < 0.05).The administration of PAP with NIC may induce sufficient hyperemia and prevent fatal arrhythmia through reductions in the PAP-induced QTc prolongation during FFR measurement.

Ruptured sinus of valsalva aneurysm presenting as syncope and hypotension: a case report.

BACKGROUND: Unruptured sinus of valsalva aneurysm (SOVA) are typically asymptomatic, and hence can be easily ignored. Ruptured sinus of valsalva aneurysm (RSOVA) usually protrude into the right atrium or ventricular. However, in this case, the RSOVA protruded into the space between the right atrium and the visceral pericardium leading to compression of the right proximal coronary artery. Very few such cases have been reported till date. CASE PRESENTATION: We describe a case of ruptured right SOVA in a 61-year-old man with syncope and persistent hypotension. At the beginning, considered the markedly elevated troponin, acute myocardial infarction was considered. However, emergency coronary angiography unexpectedly revealed a large external mass compressed right coronary artery (RCA) resulting in severe proximal stenosis. Then, aorta computed tomography angiography (CTA) and urgent surgery confirmed that the ruptured right SOVA led to external compression of the right proximal coronary artery. Finally, ruptured right SOVA repair and RCA reconstruction were successfully performed, and the patient was discharged with no residual symptoms. CONCLUSIONS: It is very important to be vigilant about the existence of SOVA. RSOVA should be suspected in a patient presenting with acute hemodynamic compromise, and echocardiography should be immediately performed. Moreover, it is very important to achieve dynamic monitoring by using cardiac color ultrasound. Definitive diagnosis often requires cardiac catheterization, and an aortogram should be performed unless endocarditis is suspected.

Physiological significance of pericoronary inflammation in epicardial functional stenosis and global coronary flow reserve.

Both fractional flow reserve (FFR) and global coronary flow reserve (g-CFR) provide prognostic information in patients with stable coronary artery disease (CAD). Inflammation plays a vital role in impaired endothelial dysfunction and atherosclerotic progression, potentially predicting cardiovascular mortality. This study aimed to evaluate the physiological significance of pericoronary adipose tissue inflammation assessed by CT attenuation (PCATA) in epicardial functional stenosis severity and g-CFR in patients with CAD. A total of 131 CAD patients with a single de novo epicardial coronary stenosis who underwent coronary CT-angiography (CCTA), phase-contrast cine-magnetic resonance imaging (PC-CMR) and FFR measurement were studied. PCATA was assessed using the mean CT attenuation value. G-CFR was obtained by quantifying absolute coronary sinus flow (ml/min/g) by PC-CMR at rest and during maximum hyperemia. Median FFR, g-CFR, and PCATA values were 0.75, 2.59, and - 71.3, respectively. Serum creatinine, NT-proBNP, left ventricular end-diastolic volume, and PCATA were independently associated with g-CFR. PCATA showed a significant incremental predictive efficacy for impaired g-CFR (< 2.0) when added to the clinical risk model. PCATA was significantly associated with g-CFR, independent of FFR. Our results suggest the pathophysiological mechanisms linking perivascular inflammation with g-CFR in CAD patients.

Real-world clinical and cost analysis of CT coronary angiography and CT coronary angiography-derived fractional flow reserve (FFRCT)-guided care in the National Health Service.

AIM: To quantify the real-world clinical and cost impact of computed tomography (CT) coronary angiography (CTCA)-derived fractional flow reserve (FFRCT) in the National Health Service (NHS). MATERIALS AND METHODS: Consecutive clinical CTCA examinations from September to December 2018 with ≥1 stenosis of ≥25% underwent FFRCT analysis. The Heart Team reviewed clinical data and CTCA findings, blinded to FFRCT values, and documented hypothetical consensus management. FFRCT results were then unblinded and hypothetical consensus management re-recorded. Diagnostic waiting times for management pathways were estimated. A per-patient cost analysis for diagnostic certainty regarding coronary artery disease (CAD) management was performed using 2014-2020 NHS tariffs for pre- and post-FFRCT pathways. RESULTS: Two hundred and fifty-one CTCAs were performed during the study period. Fifty-seven percent (145/251) had no CAD or stenosis <25%. One study was non-diagnostic. Of the remaining 42% (105/251), two were ineligible for FFRCT and there was a 5% (5/103) failure rate. FFRCT led to a change in hypothetical management in 65% (64/98; p<0.001) patients with a functional imaging test cancelled in 17% (17/98) and a diagnostic angiogram cancelled in 47% (46/98). FFRCT-guided management had a reduced mean time to definitive investigation compared with CTCA alone (28 ± 4 versus 44 ± 4 days; p=0.004). Using the proposed 2020/21 tariff, CTCA + FFRCT for stenosis ≥50% resulted in a diagnostic pathway £44.97 more expensive per patient than usual care without FFRCT. CONCLUSIONS: In the real-world NHS setting, FFRCT-guided management has the potential to rationalise patient management, accelerate diagnostic pathways, and depending on the stenosis severity modelled, may be cost-effective.

The Full Revasc (Ffr-gUidance for compLete non-cuLprit REVASCularization) Registry-based randomized clinical trial.

BACKGROUND: Complete revascularization in ST elevation myocardial infarction (STEMI) patients with multivessel disease has resulted in reduction in composite clinical endpoints in medium sized trials. Only one trial showed an effect on hard clinical endpoints, but the revascularization procedure was guided by angiographic evaluation of stenosis severity. Consequently, it is not clear how Fractional Flow Reserve (FFR)-guided percutaneous coronary intervention (PCI) affects hard clinical endpoints in STEMI. METHODS AND RESULTS: The Ffr-gUidance for compLete non-cuLprit REVASCularization (FULL REVASC) - is a pragmatic, multicenter, international, registry-based randomized clinical trial designed to evaluate whether a strategy of FFR-guided complete revascularization of non-culprit lesions, reduces the combined primary endpoint of total mortality, non-fatal MI and unplanned revascularization. 1,545 patients were randomized to receive FFR-guided PCI during the index hospitalization or initial conservative management of non-culprit lesions. We found that in angiographically severe non-culprit lesions of 90-99% severity, 1 in 5 of these lesions were re-classified as non-flow limiting by FFR. Considering lesions of intermediate severity (70%-89%), half were re-classified as non-flow limiting by FFR. The study is event driven for an estimated follow-up of at least 2.75 years to detect a 9.9%/year>7.425%/year difference (HR = 0.74 at 80% power (α = .05)) for the combined primary endpoint. CONCLUSION: This large randomized clinical trial is designed and powered to evaluate the effect of complete revascularization with FFR-guided PCI during index hospitalization on total mortality, non-fatal MI and unplanned revascularization following primary PCI in STEMI patients with multivessel disease. Enrollment completed in September 2019 and follow-up is ongoing.