NEUTROPHIL-LYMPHOCYTE RATIO AND PLATELET-LYMPHOCYTE RATIO AS PREDICTORS OF CORONARY MICROCIRCULATORY DISEASE OCCURRENCE AND OUTCOME IN PATIENTS WITH CHRONIC CORONARY SYNDROME AND NO SIGNIFICANT CORONARY ARTERY STENOSIS.

OBJECTIVE: Introduction: Index of microcirculatory resistance assessment is an invasive method of measuring coronary microcirculation function. Association between impaired microcirculatory function and higher rate of cardiovascular events was proven. Neutrophil-lymphocyte ratio and platelet-lymphocyte ratio seem to be a promising parameters to predict coronary microcirculatory disease in patients with chronic coronary syndrome. The aim: To determine neutrophil-lymphocyte ratio and platelet-lymphocyte ratio levels in patients with coronary microcirculatory disease and potential association with clinical outcome. PATIENTS AND METHODS: Material and methods: 82 consecutive patients with mean age of 67 years, 67% male, were tested for presence of coronary microcirculatory disease using index of microcirculatory resistance. Neutrophil-lymphocyte ratio and platelet-lymphocyte ratio were calculated based on admission full blood count. Follow-up with major adverse cardiac and cardiovascular events registration was performed (median 24 months). RESULTS: Results: The study showed significantly higher neutrophil-lymphocyte ratio and platelet-lymphocyte ratio in patients with coronary microcirculatory disease compared to control group (3.58±2.61 vs 2.54±1.09 and 164±87.9 vs 124±36.6 respectively). Higher level of platelet-lymphocyte ratio in patients with coronary microcirculatory disease results in worse MACCE-free survival. Optimal cut-off values of neutrophil-lymphocyte ratio and platelet-lymphocyte ratio to detect coronary microcirculatory disease were 3.2 and 181.3, respectively. CONCLUSION: Conclusions: Higher neutrophil-lymphocyte ratio and platelet-lymphocyte ratio are associated with increased index of microcirculatory resistance value. Platelet-lymphocyte ratio may be used as a predictor of worse outcome in patients with coronary microcirculatory disease.

Heterogeneous and overlapping mechanisms of ischemia and non-obstructive coronary arteries: in-hospital results of the MOSAIC-COR registry.

INTRODUCTION: Ischemia and non-obstructive coronary arteries (INOCA) remains a significant clinical issue. Recent guidelines underscore the importance of comprehensive coronary physiology assessments to make specific diagnoses and implement tailored treatment strategies. OBJECTIVES: The primary objective was to implement the comprehensive invasive diagnostics. The secondary objective was to determine the pathomechanism of INOCA in consecutive adult patients with symptomatic chronic coronary syndrome, non-invasive evidence of myocardial ischemia, and non-obstructive coronary artery disease included in the prospective MOSAIC-COR registry, and therefore, to define new INOCA subgroups. PATIENTS AND METHODS: All patients underwent comprehensive coronary physiological assessments, including resting full-cycle ratio (RFR), fractional flow reserve (FFR), index of microcirculatory resistance (IMR), and coronary flow reserve (CFR) using a pressure wire and thermodilution method. Coronary artery reactivity was assessed with acetylcholine in a provocative test. RESULTS: A total of 173 patients were enrolled (median age 66 years, 66% female). A high prevalence of typical cardiovascular risk factors was registered. According to physiological assessment, patients were divided into the following subgroups: epicardial vasospastic angina (EVSA) (19%), microvascular vasospastic angina (MVSA) (19%), coronary microcirculatory disease (CMD) (11%), EVSA+CMD (21%), MVSA+CMD (18%), and non-coronary disorder (12%). The diagnosis of MVSA and MVSA+CMD had a higher representation of females (76% and 94%, respectively). CONCLUSIONS: Patients diagnosed with INOCA in the MOSAIC-COR registry exhibit significant symptomatology and a high prevalence of typical cardiovascular risk factors. Myocardial ischemia in this population may be generated by various pathomechanisms which may overlap.

The change of angina levels in patients with chronic coronary syndromes and coronary microcirculatory dysfunction - a prospective study with 24 months follow-up.

Introduction: A substantial proportion of patients with chronic coronary syndromes suffer from angina even after medical treatment and revascularization. Coronary microvascular dysfunction (CMD) is discussed as a potential mechanism. Aim: To assess angina status in patients with chronic coronary syndromes undergoing functional assessment of coronary circulation regarding the presence of coronary microcirculatory dysfunction. Material and methods: The study included 101 consecutive patients referred for coronary angiography requiring functional stenosis assessment, with median age of 66 years, 74% male, diagnosed or treated for dyslipidemia (91%) and diabetes type 2 (42%), 20% with a history of prior non-ST myocardial infarction. Fractional flow reserve (FFR), coronary flow reserve (CFR), resistive reserve ratio (RRR), and index of microcirculatory resistance (IMR) were measured. The diagnosis of CMD was defined by either IMR ≥ 25 units or CFR ≤ 2.0 in case of no significant stenosis. A change of one CCS class over 24 months follow-up was considered clinically significant. Results: In patients without CMD diagnosis, there was a significant decrease in angina intensity (p < 0.001). Lack of angina improvement was associated with lower median RRR (2.30 (1.70, 3.30) vs. 3.05 (2.08, 4.10), p = 0.004) and lower median CFR (1.90 (1.40, 2.50) vs. 2.30 (IQR: 1.60, 3.00), p = 0.021), as compared to patients with angina improvement. Conclusions: The presence of CMD is a risk factor for no angina improvement. Impaired coronary resistive reserve ratio and lower microvascular reactivity may be one of the pathomechanisms leading to the lack of angina improvement in patients with chronic coronary syndromes.

Impaired coronary flow reserve in patients with poor type 2 diabetes control: Preliminary results from prospective microvascular dysfunction registry.

BACKGROUND: Type 2 diabetes (DM) is a common comorbidity associated with cardiovascular disease, especially when poor glucose control is present. Extracardiac microcirculatory complications prevalence is well documented, however coronary microcirculatory dysfunction (CMD) seem to be underreported in this group. METHODS: The present study analyzed coronary physiology measurements (coronary flow reserve [CFR], index of microcirculatory resistance [IMR], resistance reserve ratio [RRR]) in 47 diabetic patients (21 subjects with poor glycemia control defined as fasting glucose levels > 7.2 mmol/L and 26 with normal fasting glucose), and compared to 54 non-diabetic controls, who had undergone coronary angiography due to symptoms of chronic coronary syndrome. The median age of patients was 65.5 [59.0; 73.0] years old, 74% male, similar in terms of cardiovascular risk factors and prior myocardial infarction. Insulin was used by 19% of diabetic patients with poor glucose control and by 15% of those with DM and low fasting glucose. RESULTS: Prevalence of CMD was 38% in poor glycemia control patients, 27% in DM-patients with proper glucose control and 31% of non-diabetics. Median CFR values were the lowest in poor DM control patients compared to both, normal fasting glucose (1.75 [1.37; 2.32] vs. 2.30 [1.75; 2.85], p = 0.026) and to non-diabetics (1.75 [1.37; 2.32] vs. 2.15 [1.50; 2.95], p = 0.045). Levels of IMR, RRR and MRR did not differ significantly between compared groups (p > 0.05 for all comparisons). CONCLUSIONS: Poor glycemia control in type 2 DM might be associated with a higher prevalence of CMD driven by decreased coronary flow reserve, however, further research in larger groups of patients should be performed to confirm this observation.

The impact of coronary microvascular dysfunction on the discordance between fractional flow reserve and resting full-cycle ratio in patients with chronic coronary syndromes.

Background: Resting full-cycle ratio (RFR) is an alternative to fractional flow reserve (FFR) for the evaluation of borderline coronary artery lesions. Although FFR and RFR results are discordant in some cases, factors associated with the discordance remain unclear. The role of coronary microvascular dysfunction (CMD) is discussed as a potential mechanism to explain these discrepancies. Aim: The study aimed to assess concordance between RFR and FFR in a real-life cohort from a high-volume center regarding the role of CMD. Methods: Consecutive patients with borderline coronary lesions undergoing coronary functional testing for chronic coronary syndromes were included in the study. Measurements of RFR and FFR were performed alongside additional coronary flow reserve (CFR), resistance reserve ratio (RRR), and an index of microcirculatory resistance (IMR) measurements. CMD was defined according to the current guideline by either IMR ≥25 or CFR ≤2.0 in vessels with no significant stenosis. Results: Measurements were performed in 157 coronary arteries, in 101 patients, with a median age of 66 y., 74% male, with prior history of arterial hypertension (96%), dyslipidaemia (91%), and diabetes (40%). The median value of vessel diameter stenosis was 45% according to QCA.Overall, FFR and RFR values were significantly correlated (r = 0.66, p < 0.001), where positive FFR/negative RFR and negative FFR/positive RFR were observed in 6 (3.8%) and 38 (24.2%) of 157 vessels. The RFR/FFR discrepancy was present in 44 (28%) of measurements. CMD was confirmed in 28 (64%) of vessels with discrepant RFR/FFR and in 46 (41%) of vessels with concordant results (p = 0.01). In discordant RFR/FFR vessels, as compared to concordant ones, significantly lower values of CFR [median 1.95 (IQR: 1.37, 2.30) vs. 2.10 (IQR: 1.50, 3.00), p = 0.030] and RRR [median 2.50 (IQR: 1.60, 3.10) vs. 2.90 IQR (1.90, 3.90), p = 0.048] were observed.Main predictors of RFR/FFR discrepancy in a univariate regression analysis were: higher age of patients [OR = 1.06 (1.01; 1.10), p = 0.010], presence of CMD [OR = 2.51 (1.23; 5.25), p = 0.012], lower CFR [OR = 1.64 (1.12; 2.56), p = 0.018], and lower RRR values [OR = 1.35 (95% CI: 1.03; 1.83), p = 0.038]. Conclusion: In discrepant RFR/FFR vessels, CMD is more prevalent than in concordant RFR/FFR measurements, which can be driven by lower CFR or RRR values. Further research is needed to confirm this observation.

Clinical Characteristics Predicting Worse Long-Term Outcomes in Patients with Myocardial Infarction and Non-Obstructive Coronary Arteries (MINOCA).

Non-obstructive coronary artery disease occurs in 3.5-15% of patients presenting with acute myocardial infarction. This group of patients has a poor prognosis. Identification of factors that predict worse outcomes in myocardial infarction with non-obstructive coronary arteries (MINOCA) is therefore important. Patients with a diagnosis of MINOCA (n = 110) were enrolled in this single-center, retrospective registry. Follow-up was performed 12, 24 and 36 months after discharge. The primary composite endpoint was defined as myocardial infarction, coronary revascularization, stroke or TIA, all-cause death, or hospital readmission due to any cardiovascular event. The mean age of the study group was 64.9 (± 13.5) years and 38.2% of patients were male. The occurrence of the primary composite endpoint was 36.4%. In a COX proportional hazards model analysis, older age (p = 0.027), type 2 diabetes (p = 0.013), history of neoplasm (p = 0.004), ST-segment depression (p = 0.018) and left bundle branch block/right bundle branch block (p = 0.004) by ECG on discharge, higher Gensini score (p = 0.022), higher intraventricular septum (p = 0.007) and posterior wall thickness increases (p = 0.001) were shown to be risk factors for primary composite endpoint occurrence. Our study revealed that several factors such as older age, type 2 diabetes, ST-segment depression and LBBB/RBBB in ECG on discharge, higher Gensini score, and myocardial hypertrophy and history of neoplasm may contribute to worse clinical outcomes in MINOCA patients.

OCT Findings in MINOCA.

Myocardial infarction with non-obstructive coronary artery disease (MINOCA) is a working diagnosis for patients presenting with acute myocardial infarction without obstructive coronary artery disease on coronary angiography. It is a heterogenous entity with a number of possible etiologies that can be determined through the use of appropriate diagnostic algorithms. Common causes of a MINOCA may include plaque disruption, spontaneous coronary artery dissection, coronary artery spasm, and coronary thromboembolism. Optical coherence tomography (OCT) is an intravascular imaging modality which allows the differentiation of coronary tissue morphological characteristics including the identification of thin cap fibroatheroma and the differentiation between plaque rupture or erosion, due to its high resolution. In this narrative review we will discuss the role of OCT in patients presenting with MINOCA. In this group of patients OCT has been shown to reveal abnormal findings in almost half of the cases. Moreover, combining OCT with cardiac magnetic resonance (CMR) was shown to allow the identification of most of the underlying mechanisms of MINOCA. Hence, it is recommended that both OCT and CMR can be used in patients with a working diagnosis of MINOCA. Well-designed prospective studies are needed in order to gain a better understanding of this condition and to provide optimal management while reducing morbidity and mortality in that subset patients.

Coronary revascularization after heart transplant - the search for prognostic factors.

INTRODUCTION: Survival after heart transplantation (HTX) is extended due to continuous improvement of medical care, allowing enough time for coronary artery vasculopathy to develop. Data on the clinical outcome of cardiac transplantation patients after percutaneous coronary intervention (PCI) are still not extensively explored. The aim of our study was to assess whether heart transplantation itself compromises the outcome in patients undergoing percutaneous coronary intervention and to assess survival rates as well as major cardiovascular complications in heart transplant recipients who had undergone PCI. MATERIAL AND METHODS: Thirty-three heart transplant recipients who had undergone PCI in the years 2005 to 2015 in a single center were matched by age, sex and main risk factors of arteriosclerosis with 33 controls without heart transplant history. Mean age of patients was 54.6 ±11.4 years in the HTX group and 58.8 ±10.8 years in controls. Median time from heart transplant to PCI was 13 years (4.4-22 years). Case and control groups did not differ in terms of standard risk factors of coronary artery disease, apart from chronic kidney disease, which was present in 70% of patients after heart transplantation, and dyslipidemia, which was present in 91% of control subjects. RESULTS: Patients after HTX had worse survival compared to controls (p = 0.04). When adjusted for comorbidities in the Cox regression model, there was no significant difference in survival between cardiac transplant recipients and the control group (HR = 1.06; 95% CI: 0.10-11.24). Chronic renal disease was a significant predictor of all-cause mortality (HR = 29.9; 95% CI: 2.3-393). Considering other endpoints, HTX patients had considerably higher incidence of severe bleeding compared to the control group (27% vs. 3%, p < 0.05). CONCLUSIONS: There was no significant difference in myocardial infarction rate, revascularization or hospitalization rates.

Effect of short-term fluctuations in outdoor air pollution on the number of hospital admissions due to acute myocardial infarction among inhabitants of Kraków, Poland.

INTRODUCTION Air pollution is reaching alarming proportions worldwide; however, previous studies concerning the association between air pollution and myocardial infarction (MI) provided conflicting results. OBJECTIVES We evaluated a relationship between short­term fluctuations in outdoor particulate matter (PM) and nitrogen dioxide (NO2) levels and the number of hospitalizations due to MI among the inhabitants of Kraków, Poland. PATIENTS AND METHODS Data on hospitalizations, daily pollutant concentrations, infections, and meteorological parameters were collected from December 2012 to September 2015. Data were assessed using a time­series regression analysis with a distributed lag model. RESULTS An increase of 10 µg/m3 in PM2.5 levels was associated with a higher risk of hospital admission due to MI (odds ratio [OR], 1.32; 95% CI, 1.01-1.40; P = 0.0002). For PM10 the effect was observed only with a simultaneous decrease of 1ºC in the mean daily temperature (OR, 1.08; 95% CI, 1.01-1.17; P = 0.03). Significant effects were observed at lags 5 and 6. The effect of NO2 was significant at lags 0 and 1, but only in patients aged 70 years or older (OR, 1.13; 95% CI, 1.01-1.23; P = 0.007) and those with pulmonary disorders (OR, 1.12; 95% CI, 1.01-1.31; P = 0.01). CONCLUSIONS In all age groups, the short­term elevation in PM2.5 levels was associated with an increased number of daily hospital admissions for MI, whereas for PM10 the effect was significant only with a simultaneous decrease in temperature. The effect of NO2 was observed only in older individuals and patients with pulmonary disorders. A negative clinical effect was more delayed in time in the case of exposure to PM than to NO2.