Coronary Artery Disease – ABC CARDIOL

IJCS

Original Article

Myocardial Infarction with Non-Obstructive Coronary Arteries: Clinical Profile, Diagnostic Investigation, and Outcomes in a Tertiary Center Cohort

Kelvyn Vital et al. Ricardo Pavanello Barbara Porto Valente Bruno Noshang Blaas … Bianca Fernandes Tavora Arruda Raphael Rossi Maria Isabel Del Monaco Fausto Feres

Abstract

Background:

Myocardial infarction with non-obstructive coronary arteries (MINOCA) represents a heterogeneous clinical syndrome associated with diverse pathophysiological mechanisms and a non-negligible prognosis. Despite conceptual advances, diagnostic uncertainties and significant variations in etiological investigation and clinical management persist in real-world practice, particularly in centers with limited access to advanced imaging modalities.

Objectives:

To describe the clinical profile, diagnostic strategies employed, and clinical outcomes of patients with MINOCA followed at a Brazilian tertiary center.

Methods:

Observational, retrospective study including consecutive patients diagnosed with MINOCA, defined according to the Fourth Universal Definition of Myocardial Infarction and European guidelines. Clinical, angiographic, and complementary diagnostic data, as well as the treatment instituted and clinical outcomes during follow-up, were collected.

Results:

A total of 196 patients were included, with a mean age of 50.6 ± 11.8 years and a slight female predominance (52.6%). Systemic arterial hypertension (60.2%), dyslipidemia (45.9%), and current or former smoking (48.0%) were frequent. Cardiac magnetic resonance imaging was performed in 42.3% of cases, whereas intracoronary imaging methods were rarely used (2.6%). In 40.8% of patients, a definitive etiology could not be established. During follow-up (n = 183), mortality was 3.8%, reinfarction occurred in 6.6%, and new cardiovascular hospitalizations occurred in 16.9%.

Conclusions:

Patients with MINOCA present an intermediate-risk clinical profile and a relevant incidence of cardiovascular events during follow-up. The high proportion of cases without a defined etiological diagnosis reflects limitations in investigation and reinforces the need for more structured diagnostic strategies and individualized clinical management.

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IJCS

Original Article

Genetic Evidence for the Association Between Sjögren's Syndrome and Cardiovascular Disease Risk

Yafang Gao et al. Guohua Wu Tianyu Jin Zhijie Shen … Nannan Zhou Xiaohong Huang

Abstract

Background:

Previous studies have indicated that patients with Sjögren’s syndrome (SS) exhibit an increased risk of cardiovascular disease (CVD). However, the causal association between SS and CVD risk remains to be elucidated.

Objectives:

This investigation explored the genetic relationship between SS and CVD risk through Mendelian randomization (MR).

Methods:

We identified the genetic association between SS and CVD incidence via two-sample MR analysis based on summary statistics from publicly available genome-wide association studies (GWAS). The inverse-variance weighting (IVW) method was used for the primary analysis in our study. Additionally, we conducted several sensitivity analyses to confirm the stability and reliability of the MR results.

Results:

MR analysis revealed that SS was not significantly associated with the risk of various CVDs, including atrial fibrillation (AF) (odds ratio [OR] = 0.98, 95% confidence interval [CI] = 0.95–1.01; p = 0.22), ischemic stroke (IS) (OR = 0.99, 95% CI = 0.93–1.05; p = 0.68), heart failure (HF) (OR = 1.00, 95% CI = 0.96–1.04; p = 0.91), coronary artery disease (CAD) (OR = 0.99, 95% CI = 0.94–1.04; p = 0.60), and myocardial infaion (MI) (OR = 1.01, 95% CI = 0.97–1.06; p = 0.61).

Conclusions:

Our MR study did not provide genetic evidence supporting a causal association between SS and CVD incidence. The associations reported in prior observational studies may be due to residual confounding and reverse causality.

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IJCS

Original Article

Reversal of Therapeutic Recommendations in the American College of Cardiology Coronary Artery Disease Guidelines

Alessandra Carvalho Caldas et al. Denise Matias Daniel Medina Luis Claudio Lemos Correia

Abstract

Background:

Medical reversal is defined as the discontinuation of a procedure’s recommendation due to new evidence regarding its efficacy or safety. Cardiology is the specialty with the highest number of documented reversals, yet there is no information available about the probability of reversal.

Objectives:

To describe the frequency of medical reversal in the ischemic heart disease guidelines published by the American College of Cardiology/American Heart Association (ACC/AHA), according to levels of evidence.

Methods:

The most recent guidelines for stable coronary disease, non-ST-elevation acute coronary syndrome, and ST-elevation myocardial infarction were compared with the first version. Medical reversal was defined as a shift from a recommended procedure to a contraindicated one or the removal of the recommendation. The quality of evidence was categorized by the guidelines as high, moderate, or low.

Results:

A total of 224 therapeutic recommendations were identified, with 19% based on high-quality evidence, 42% on moderate-quality evidence, and 39% on low-quality evidence. Forty-nine medical reversals were observed, constituting 22% of all therapeutic recommendations included in the first version of the guidelines. The probability of reversal for procedures based on high-quality evidence was 2%, compared with 25% for procedures with moderate-quality evidence and 30% for procedures with low-quality evidence.

Conclusion:

In the ACC/AHA ischemic heart disease guidelines, medical reversal is common in recommendations based on moderate or low-quality evidence, but rare in those with high-quality evidence.

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IJCS

Viewpoint

Asymptomatic Patients With Suspected Coronary Artery Disease: What Are Clinicians Afraid Of?

Antônio Sérgio Cordeiro da Rocha et al. Dany Kruczan

Introduction

In contemporary practice, myocardial revascularization, particularly Percutaneous Coronary Intervention (PCI), is frequently performed in asymptomatic individuals with suspected Coronary Artery Disease (CAD). This occurs despite robust evidence from Randomized Clinical Trials (RCTs) over the past two decades demonstrating that, in patients with Chronic Coronary Syndromes (CCS), neither PCI nor Coronary Artery Bypass Grafting (CABG) reduces mortality when compared with Guideline-directed Medical Therapy (GDMT). In selected populations, revascularization confers symptomatic relief, particularly among patients with frequent angina, but without prognostic advantage.

The persistence of invasive strategies in asymptomatic patients appears to be driven largely by two cognitive biases: the “oculostenotic reflex”, the impulse to correct angiographically visible stenoses, and the “oculoischemic reflex”, the perceived need to revascularize documented ischemia irrespective of symptoms. Both are rooted in the fear that untreated coronary obstructions inevitably herald sudden cardiac death or Acute Myocardial Infarction (AMI).^,

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IJCS

Original Article

Treatment Adherence and Cardiometabolic Goals in Patients with Coronary Artery Disease in the North Region of Brazil

Fernando Maia Coutinho et al. Talles L. Pereira Nogueira Dilma do Socorro Moraes de Souza Lucianna Serfaty de Holanda … Vitor Bruno Teixeira de Holanda Michele N. Assad Rafael M. Coutinho Ana Flávia Oliveira de Souza Márcio César Ribeiro Marvão Thiago da Silva Paulo

Abstract

Background:

Patients with coronary artery disease (CAD) are categorized by cardiovascular risk depending on associated risk factors and events, requiring more rigorous treatment goals.

Objective:

To investigate treatment adherence, using the Morisky–Green test, and achievement of metabolic goals at a tertiary public hospital in Belém, Pará, Brazil.

Methods:

This observational, cross-sectional, and analytical study was conducted with a sample of 106 patients with CAD at very high cardiovascular risk, treated in the outpatient clinic of a tertiary care hospital. The following data were collected over a 4-month period: demographic information, medication adherence (Morisky–Green test), modifiable risk factors, and laboratory parameters (lipids, blood glucose, blood pressure, heart rate, and abdominal circumference). Associations were assessed using chi-square test or G test, and correlations were analyzed using Spearman’s test, adopting a significance level of 5% (p < 0.05).

Results:

Treatment adherence analysis showed an adherence rate of 16.0%. Low-density lipoprotein (LDL) -cholesterol levels were above the target of 50 mg/dL in 72.6% of patients, and normal blood glucose was achieved in 75.5%. Education level was the only epidemiological variable associated with therapeutic non-adherence (p = 0.0130). Regarding financial aspects, only 9.4% reported persistent difficulty in purchasing medications; among those reporting difficulty, high-potency statins were the most frequently cited (58.6%).

Conclusions:

Education level was shown to be a determining factor in understanding treatment, impacting adherence. Laboratory tests revealed significant deficiencies in lipid control, reinforcing the need for clinical optimization. Difficulties in accessing statins and low medication adherence underscore the importance of educational interventions and multidisciplinary approaches for better management of CAD.

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IJCS

Original Article

Association Between Inflammatory Hematologic Indices and Acute Coronary Syndrome Phenotypes

Fabiele de Lima Righi et al. Gustavo Sugai Paula Araujo Renato Jorge Alves

Abstract

Background:

The systemic immune-inflammation index (SII) and the systemic inflammation response index (SIRI) are inflammatory biomarkers derived from neutrophil (N), platelet (P), lymphocyte (L), and monocyte (M) counts. These indices have been associated with prognostic value in patients with coronary artery disease (CAD) and may contribute to risk stratification in acute coronary syndrome (ACS).

Objectives:

To evaluate the independent association between inflammatory hematologic indices and ACS phenotypes and to explore their relationship with cardiovascular risk factors.

Methods:

This retrospective study analyzed data collected from medical records between July 2022 and July 2023, including 333 patients aged ≥ 18 years of both sexes diagnosed with ACS and admitted to the emergency department of a public hospital in the state of São Paulo, Brazil. Sample was divided into two groups: i) ST-segment elevation myocardial infarction (STEMI) and ii) non-ST-segment elevation myocardial infarction plus unstable angina (NSTEMI+UA). SII was calculated as N × P / L and SIRI as N × M / L. The association between inflammatory indices and ACS phenotypes was assessed using multivariable logistic regression models. Statistical significance was set at 5%.

Results:

Higher values of the inflammatory indices SII (odds ratio [OR], 2.27; 95%CI, 1.66-3.10) and SIRI (OR, 2.92; 95%CI, 2.15-3.96), as well as a history of smoking, were independently associated with a higher likelihood of STEMI diagnosis. Additionally, the STEMI group showed significantly higher values of SII, SIRI, MLR, NLR, and PLR compared with the NSTEMI+UA group.

Conclusions:

Higher SII and SIRI values were independently associated with STEMI diagnosis, which suggests these indices may reflect differences in the inflammatory profile across ACS phenotypes.

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IJCS

Editorial

Coronary Artery Disease In Maintenance Hemodialysis Patients: Are We Acting Too Late?

Jorge Paulo Strogoff de Matos et al. Jocemir Ronaldo Lugon

The study by França et al. confirms the well-known high prevalence of Coronary Artery Disease (CAD) and the high mortality rate among patients with Chronic Kidney Disease (CKD) undergoing maintenance hemodialysis, which is mainly due to cardiovascular causes. The authors also found a significantly higher crude mortality rate among those who were not under statin use. However, this should be cautiously interpreted since no adjustment was made for confounding factors, and a bias cannot be ruled out, for example, that statins were not prescribed to those patients with a very low remaining life expectancy who would likely not benefit from the therapy.

The population undergoing renal replacement therapy is increasing worldwide. In Brazil alone, there are currently more than 150,000 patients on maintenance dialysis. In general, these patients are stratified and treated for CAD based on guidelines derived mainly from evidence from clinical trials in which, due to the study design, patients on dialysis therapy or those with advanced CKD were excluded.

[…]

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IJCS

Original Article

Exploring Risk Factors, Comorbidities, and Multiple Drug Therapy in Coronary Artery Disease Patients

Ketan Inamdar et al. Harshada Kajave Akash Shete Jayant Pawar … Anmaria Thomas Madhur Kulkarni

Abstract

Background:

Coronary artery disease (CAD) continues to be a predominant global cause of morbidity and mortality, with rising prevalence in developing nations like India, emphasizing the need to address risk factors, multimorbidity, and polypharmacy to implement effective lifestyle interventions and drug therapies to enhance patient outcomes.

Objectives:

To evaluate the risk factors, comorbidities, and multiple drug therapy patterns among patients diagnosed with CAD in a tertiary care setting.

Methods:

This prospective observational study used medical records to collect data on demographics, comorbidities, lifestyle factors, and medications. Descriptive statistics summarized findings, and Chi-square tests assessed associations between gender, risk factors, and CAD. The significance level adopted in the statistical analysis was 5%.

Results:

Out of 300 patients enrolled, 69.3% were male, and the highest disease prevalence was noted in the 66–75 age group. Hypertension was the most common comorbidity (71%), followed by diabetes mellitus (DM) (50%). Poor diet was the leading lifestyle risk factor (25.3%), followed by smoking (21%). A significant association existed between gender and CAD type (p = 0.002), with females showing higher angina prevalence and males showing more myocardial infarction (MI). For CAD management, aspirin (92.6%) and enoxaparin (59.3%) were most frequently prescribed, followed by atorvastatin (53.6%) and nicorandil (52%). For comorbidity management, beta-blockers (59.6%) and insulin (48.7%) were commonly prescribed. Increased use of ticagrelor and dapagliflozin was observed, indicating a greater alignment with evidence-based guideline recommendations.

Conclusion:

This study highlights the burden of multimorbidity and polypharmacy among CAD patients in India, emphasizing the need for individualized, evidence-based therapy.

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IJCS

Editorial

Myocardial Perfusion Imaging: Always Evolving

Renata Christian Martins Felix

Myocardial perfusion assessed by nuclear medicine began to be used in clinical practice in the 1970s with the radiotracer 201-thallium chloride in two-dimensional images.

Advances in the development of equipment, from the possibility of three-dimensional images by single-photon emission computed tomography (SPECT), and new tracers, such as those linked to 99-technetium, have allowed the consolidation of nuclear cardiology as a non-invasive tool with high diagnostic accuracy in the context of coronary artery disease.

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IJCS

Original Article

Prognostic Value of Myocardial Perfusion Scintigraphy with IQ∙SPECT Technology in Patients with Suspected or Known Coronary Artery Disease

Maria Fernanda Rezende et al. Davi Shunji Yahiro Fernando de Amorim Fernandes Jader Azevedo Claudio Tinoco Mesquita

Abstract

Background:

IQ∙SPECT is a collimator design coupled with a cardio-centric acquisition orbit and specific reconstruction algorithm that increases camera efficiency. However, there is no prognostic data derived from IQ∙SPECT exams.

Objectives:

To evaluate the prognostic value of IQ∙SPECT myocardial perfusion scintigraphy (MPS) in patients with suspected or known coronary artery disease (CAD).

Methods:

The study population consisted of 734 consecutive patients with suspected or known CAD submitted to MPS with IQ∙SPECT. Adequate follow-up was obtained in 625 patients. We retrospectively analyzed imaging and clinical data. The follow-up was obtained for no less than 12 months after the MPS study. Statistical significance was taken at p < 0.05.

Results:

Normal IQ∙SPECT compared to abnormal IQ∙SPECT had lower annualized incidence of hard events (0.2% and 1.1%, respectively, p = 0.02), late combined events (1.1% and 5.5%, respectively, p = 0.008), and revascularization (1% and 14%, respectively, p < 0.001). Left ventricular ejection fraction ≤ 45% was found to be the only clinical predictor of hard events (p < 0.0003, confidence interval [CI] = 5.25 to 129.02). However, for combined events, abnormal MPS (p < 0.0001, CI = 3.39 to 11.13, hazard ratio [HR] = 6.14) and dyspnea/fatigue (p = 0.013, CI = 1.28 to 8.4, HR = 3.3) obtained statistical significance. In contrast, ischemic burden ≥ 5% (p < 0.0001, HR = 30.3) was the most relevant parameter for revascularization, followed by thoracic pain (p = 0.002, HR = 2.4).

Conclusion:

Our study demonstrates that IQ SPECT MPS has significant prognostic capabilities with very low risk of adverse events in patients with normal findings.

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IJCS

Original Article

Inflammatory and Atherogenic Markers as Predictors of Coronary Artery Disease in Patients with Suspected Coronary Artery Disease Undergoing Coronary Angiography

Veysi Can et al. Fuat Polat

Abstract

Background:

Coronary artery disease (CAD) remains a leading cause of death worldwide, with inflammation playing a key role in its pathophysiology. Inflammatory biomarkers may offer valuable insights into disease mechanisms and risk stratification, potentially informing therapeutic decisions.

Objectives:

This study aimed to investigate the association between key inflammatory markers — C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) — and both the presence and severity of coronary artery stenosis (CAS) in patients with suspected CAD undergoing coronary angiography.

Methods:

This retrospective study included 767 patients referred for coronary angiography due to suspected CAD. The primary outcome was the presence of significant CAS. Demographic data, medical history, and blood samples were collected. Statistical analyses included descriptive methods and regression modeling as well as receiver operating characteristic (ROC) curve analysis to determine optimal cutoff values for biomarkers, with area under the curve (AUC) used to assess predictive performance. A p-value < 0.05 was considered statistically significant.

Results:

Of the 767 patients (mean age 58.3±12.4 years; 56.7% men), 496 had significant CAS (≥ 50%) and 271 had nonsignificant CAS (< 50%). Levels of CRP (0.44 vs. 0.13 mg/dL, p = 0.01) and NLR (2.6 vs. 2.0, p = 0.05) were significantly higher in patients with CAS. No significant difference was observed for PLR (129.4 vs. 118.6, p = 0.13). In multivariable analysis, CRP (OR = 1.188, p = 0.044) and NLR (OR=1.567, p = 0.03) were identified as independent predictors of significant CAS. However, ROC curve analysis showed limited discriminative ability for both CRP (AUC = 0.526) and NLR (AUC = 0.510), with values only slightly above chance.

Conclusion:

Increased levels of CRP and NLR are significantly associated with CAS and may serve as potential biomarkers for detecting CAD.

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Original Article

Evaluation of Different Therapeutic Approaches for Acute Coronary Syndromes in Patients Undergoing Chronic Dialysis: A Retrospective Cohort Study

Matheus Eduardo França et al. Ana Luiza de Fragas Franciani Rodrigues da Rocha Leonardo Claudino Ribeiro Silvia R. Froes Toniazzo

Abstract

Background:

Cardiovascular disease (CVD) is the leading cause of death among individuals with chronic kidney disease (CKD), particularly those undergoing dialysis, accounting for approximately 40% of deaths. The prevalence of ischemic coronary disease among patients undergoing hemodialysis over the age of 45 reaches 41%.

Objective:

To analyze outcomes of symptomatic coronary artery disease (CAD) in patients undergoing chronic dialysis, stratified by invasive assessment, and treated with one of three approaches: medical therapy alone (MTA), percutaneous coronary intervention (PCI), or coronary artery bypass grafting.

Methods:

This was a retrospective, analytical, observational cohort study based on data from electronic medical records collected between 2013 and 2023, including a total of 68 patients. Quantitative variables were analyzed using one-way Analysis of Variance (ANOVA), and qualitative variables were assessed using Pearson’s chi-square test. A p-value <0.05 was considered statistically significant.

Results:

The mean age was 60.2 ± 13.1 years, with a male predominance of 42 patients (62.8%). The highest mortality was observed in the MTA group with 25 deaths (69.4%), followed by PCI with 10 deaths (56.6%), and the lowest in the coronary artery bypass grafting group with six deaths (42.9%). Among patients who did not use statins, 19 (82.6%) died (p < 0.01). The lowest rate of readmission due to coronary syndrome occurred in the MTA group (two patients; 18.2%), while the highest was in the PCI group (six patients; 54.5%) (p = 0.02).

Conclusion:

Although no statistically significant difference in mortality was found among the three therapeutic strategies, MTA was associated with lower rates of readmission and repeat cardiac catheterization. In contrast, PCI was linked to a higher risk of readmission due to coronary syndrome.

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Original Article

Chocolate Consumption Does Not Reduce the Risk of Cardiovascular Events and Increases the Risk of Gastrointestinal Bleeding One Year After the First Myocardial Infarction

Daniel Medeiros Moreira et al. Lara Marcon Dandolini Tammuz Fattah Rodrigo de Moura Joaquim Roberto Leo da Silva

Abstract

Background

Coronary artery disease is the leading cause of death worldwide, with high social and financial costs. Although previous studies have demonstrated the potential of chocolate to reduce coronary events, data on its effects in patients who have suffered an acute myocardial infarction (AMI) are lacking.

Objective

To evaluate the impact of chocolate consumption on the incidence of events in patients with AMI followed for one year.

Methods

A subanalysis of the Catarina Heart study, which evaluated patients hospitalized with a diagnosis of the first AMI, was conducted. During hospitalization, patients were asked about their chocolate consumption before the event. The incidence of events was compared between consumers and non-consumers of chocolate before the AMI. The analyzed outcomes included major adverse cardiovascular events (MACE), all-cause mortality, cardiovascular mortality, reinfarction, stroke, in-stent restenosis, acute stent thrombosis, gastrointestinal bleeding, and bleeding requiring transfusion. Cox regression models were applied, and p < 0.05 was considered statistically significant.

Results

A total of 1404 patients were analyzed, of whom 490 (34.9%) consumed chocolate. Chocolate consumption neither reduced the risk of MACE (hazard ratio [HR] = 0.88 [0.57 – 1.37], p = 0.569) nor showed benefits in other outcomes, such as cardiovascular mortality, reinfarction, or stroke. However, its consumption was significantly associated with an increased risk of gastrointestinal bleeding (HR = 2.89 [1.16 – 7.24], p = 0.023) without increasing the risk of bleeding requiring transfusion or acute stent thrombosis.

Conclusion

Chocolate consumption before AMI did not reduce major cardiovascular events and was associated with an increased risk of gastrointestinal bleeding.

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Editorial

Integrating Insulin Resistance and Coronary Artery Disease Severity: Will Triglyceride-Glucose Index Be the Easiest Way?

Frederico Toledo Campo Dall’Orto et al. Flávia Bittar Brito Arantes Remo H. M. Furtado Pedro G. M. de Barros e Silva

Insulin resistance (IR) is a complex metabolic abnormality associated with genetic and environmental factors, which begins with low glucose metabolism in tissues, particularly in muscle, liver, and adipocytes, with consequent stimulation of pancreatic beta cells to increase insulin production and release.^– Accumulation of lipids in a variety of tissues, including muscle, liver, and pancreas, contributes to this process in a phenomenon known as “lipotoxicity.” As IR increases, it stimulates hyperinsulinemia, and this negative cycle perpetuates a metabolic disorder that is a main cause of cardiovascular diseases. In addition, insulin also acts on lipid metabolism, increasing lipid synthesis in liver and adipose cells, in addition to turning off the release of triglycerides (TG) and fatty acids in adipose and muscle tissues.

Several tests are used to identify IR, such as the oral glucose tolerance test, insulin dosage, and the hyperinsulinemic-euglycemic clamp (HIEC), which is considered the gold standard. However, HIEC is complex and time-consuming, which limits its widespread use in clinical practice. Currently, the most widely used test to assess IR is the homeostasis model assessment of insulin resistance (HOMA-IR), which has several limitations including lack of standardization (e.g., variations in laboratory, patients using antidiabetic drugs, low body mass index), calculation based on fasting parameters (which may not be representative of the entire day), and assumptions about IR that are not totally true (e.g., the assumption that IR is proportional to insulin levels and is similar in the liver and peripheral tissues, without considering variation in beta cell function).^, Recently, a new marker of IR has been designed, which is the triglyceride-glucose (TyG) index that predicts the risk of IR, diabetes, and cardiovascular disease. The TyG index is calculated by multiplying the TG value by the serum glucose level, in mg/dl, and dividing the result by 2. The TyG index is a non-invasive, low-cost marker for cardiovascular risk stratification. Since IR can be related to the development of more extensive coronary disease, this marker could also be useful to this evaluation.

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IJCS

Editorial

Platelet Distribution Width: A New Prognostic Marker for Patients with Acute Coronary Syndrome?

Angelo Roncalli Ramalho Sampaio

The study by Polat et al. published in the International Journal of Cardiovascular Sciences explored the association between platelet distribution width (PDW) and the severity and extent of coronary artery disease (CAD) in patients with acute coronary syndrome (ACS). This retrospective study involved a comprehensive analysis of clinical, angiographic, and laboratory data obtained from a consecutive cohort of 1043 patients diagnosed with ACS, stratified into two groups based on PDW values (> 11.8 fL and ≤ 11.8 fL), with the aim of investigating the association of PDW levels with the clinical severity and extent of CAD in patients diagnosed with ACS.

GRACE (Global Registry of Acute Coronary Events) score, SYNTAX score, TIMI flow grade, thrombosis grades of culprit lesions, and neutrophil-lymphocyte ratio (NLR) were calculated in patients. The associations of these with PDW were also examined.

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Original Article

Platelet Distribution Width as a Marker for Severity and Extent of Coronary Artery Disease in Acute Coronary Syndrome

Fuat Polat et al. Zeynettin Kaya Atakan Yanikoğlu

Abstract

Background

Previous studies have demonstrated an association between larger platelet volume and coronary thrombus formation in acute coronary syndrome (ACS).

Objectives

We aimed to investigate the association of platelet distribution width (PDW) levels with both the clinical severity and the extent of coronary artery disease (CAD) in patients diagnosed with ACS.

Methods

A retrospective evaluation was conducted on 1043 consecutive patients diagnosed with ACS. Patients were stratified into two groups based on their PDW values: group 1 (PDW > 11.8 fL) and group 2 (PDW ≤ 11.8 fL). For each patient, Global Registry of Acute Coronary Events (GRACE) score, SYNTAX score, Thrombolysis in Myocardial Infarction (TIMI) flow grade, thrombus grades of culprit lesions, and neutrophil–lymphocyte ratio (NLR) were calculated, and their associations with PDW were examined.

Results

The mean age of the patients was 60.1 ± 12.4 years, with the majority being male (78.5%). The mean PDW was 11.8 fL (range: 8.9 to 22.0). Patients in group 1 exhibited higher NLR (3.21 versus 2.13, p < 0.05) and higher GRACE scores (139 versus 126, p < 0.05) compared to group 2. Group 1 patients also showed lower TIMI flow grades (0 and 1). A positive correlation was observed between PDW and GRACE score (R: 0.304, p = 0.01), but not with the SYNTAX score.

Conclusion

Elevated PDW levels in patients with ACS were associated with more severe disease, as indicated by higher GRACE scores and reduced TIMI flow grades.

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Original Article

Evaluation of Prevalence, Management and Recording of Risk Factors in Outpatient Patients with Coronary Artery Disease

Alexandre Felipe Pacini et al. Gerson Luiz Bredt Junior Eline da Rós Moro Alcirley de Almeida Luiz Ana Paula de Oliveira Francez

Abstract

Background

Coronary artery disease (CAD) is the leading cause of mortality worldwide. Adequate management of risk factors is directly correlated with better outcomes.

Objectives

This study aims to identify risk factors and evaluate the indicated medical treatment (both pharmacological and non-pharmacological) in patients with CAD.

Methods

Epidemiological data were collected from electronic medical records of patients treated at Cardiology outpatient clinics of a Tertiary Hospital and a descriptive analysis of the data was performed.

Results

Patients with documented CAD (n = 230) were selected for the study, with a predominance of white (60%) men (62%), most of whom were monitored following an Acute Coronary Syndrome (ACS) (63.9%). High prevalence and irregular control of risk factors such as smoking, hypertension, dyslipidemia, diabetes, obesity, and sedentary lifestyle were observed. Target blood pressure was achieved in 52.6% of patients, low-density lipoprotein (LDL) in 5.7%, and HbA1c in 50.8%, despite appropriate prescriptions for most patients – 100% were prescribed statins, and over 90% received antiplatelet agents, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers, and beta-blockers. Few patients were encouraged to quit smoking and engage in physical activities.

Conclusion

Significant recording errors were noted in the medical records, along with inadequate control of CAD-related risk factors. Improvements in both recording and management of these risk factors are necessary to enhance CAD outcomes. The study utilized a straightforward and cost-effective model, which effectively mapped the local population profile and managed CAD risk factors.

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Original Article

Triglyceride-Glucose Index: Evaluation as a Potential New Risk Marker for SYNTAX Score in Acute Coronary Syndrome

Murat Özmen et al. Erhan Arikan Faik Ozel İsa Ardahanlı

Abstract

Background:

The triglyceride glucose (TyG) index is known to indicate conditions such as metabolic syndrome and atherosclerotic process. SYNergy between PCI with TAXUS (SYNTAX) and Cardiac Surgery scoring systems (SS) can show coronary anatomic severity and complexity because it is a quantitative and reproducible basic measurement before revascularization. There is no study in the literature investigating the relationship between the TyG index and the SYNTAX SS.

Objective:

This study aims to investigate a potential association between the TyG index and the SYNTAX score in patients with acute coronary syndrome (ACS).

Methods:

We retrospectively analyzed 214 patients hospitalized for ACS. Patient demographics and clinical characteristics were recorded, and participants were categorized into low, intermediate, and high SYNTAX score groups. The relationship between SS and TyG index was then evaluated using statistical analysis (chi-square test, p < 0.05).

Results:

The mean age of participants was 63.15 ± 12.69 years, with 67.8% being male. The majority (65.4%) had low SS, while 24.3% had intermediate SS, and 10.3% had high SS. As expected, the SYNTAX score correlated significantly with diabetes mellitus (DM) (p < 0.001). However, no statistically significant association was found between the SYNTAX score and the TyG index (p = 0.312).

Conclusion:

In patients diagnosed with ACS and undergoing coronary angiography (CAG), our study confirmed a strong link between SYNTAX score and DM. Unexpectedly, we did not find a significant relationship between the TyG index and SYNTAX score, suggesting that TyG may not directly reflect coronary artery disease (CAD) complexity as assessed by the SS.

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Original Article

Is Trimethylamine N-oxide (TMAO) Associated with NF-κB mRNA Expression in Patients with Coronary Artery Disease?

Beatriz Da Cruz et al. Karen Salve Coutinho-Wolino Ludmila Cardozo Aline D'Avila Pereira … Claudio Tinoco Mesquita Peter Stenvinkel Peter Bergman Denise Mafra Milena Barcza Stockler-Pinto

Abstract

Background:

Trimethylamine N-oxide (TMAO), a gut microbiota metabolite, is associated with cardiovascular disease (CVD) development. TMAO can trigger an inflammatory response by inducing the nuclear factor-kappa B (NF-κB) signaling cascade and increasing the expression of pro-inflammatory cytokines, contributing to the worsening of CVD. This study aimed to evaluate the association between TMAO plasma levels and inflammation in patients with coronary artery disease (CAD).

Methods:

A cross-sectional study was carried out including 29 patients with CAD. Peripheral blood mononuclear cells (PBMC) were isolated from fasting blood samples, and NF-κB and vascular cell adhesion protein 1 (VCAM1) mRNA expression were estimated using real-time quantitative PCR. We determined TMAO plasma levels by LC-MS/MS and TNF-α by ELISA. Routine biochemical parameters were evaluated using an automatic biochemical analyzer. Correlations were estimated by Spearman or Pearson test. Statistical significance was set at the level of p < 0.05.

Results:

All patients presented TMAO levels within the normal range according to EUTox (normal range: 2.83 ± 1.53 mg/L; CAD patients: 0.2 [0.1 to 0.2] ng/μL). TMAO plasma levels were positively correlated with NF-κB mRNA expression (0.555; p = 0.002).

Conclusion:

TMAO plasma levels may be associated with NF-κB mRNA expression in patients with CAD and may contribute to the pathogenesis of this disease.

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Original Article

Clinical Profile and its Associations with Coronary Angiography Results in a Public University Hospital

Guilherme Costa et al. Esmeralci Ferreira Denilson Campos Albuquerque

Abstract

Background:

Ischemic heart disease is one of the most common causes of death worldwide. There are few data in the literature about the association of clinical profile and coronary angiography results in the Brazilian population.

Objectives:

To assess clinical variables and their associations with the results of coronary angiography and to evaluate the safety of coronary angiography in a public university hospital.

Methods:

From August 2015 to April 2018, 1 844 patients submitted to coronary angiography at the Pedro Ernesto University Hospital (HUPE, acronym in Portuguese) were enrolled in this cross-sectional study. They were evaluated by their clinical variables, angiographic results, and procedure complications. Logistic regression was used, and the criterion for determining significance was set at 5%.

Results:

The median age was 62 years, and most of the population (71%) were outpatients. Stable angina was the most common indication (62.9%). Only 19.7% underwent noninvasive cardiac testing. Arterial hypertension was the most prevalent (88.2%), followed by dyslipidemia (60.2%). Most patients (65%) had obstructive coronary artery disease (CAD). Left main coronary artery (LMCA) stenosis was found in 8.1% of patients. Older age, male sex, quantity of risk factors (RF), and peripheral artery disease were risk predictors for CAD. Death occurred only in 0.16% of the population, and acute coronary artery occlusion in 0.2%.

Conclusion:

Classic RF showed an association with CAD. The low incidence of complications suggests that coronary angiography is a safe procedure to be conducted in a public university hospital.

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Original Article

miR-27a/b Level is Associated with ABCA1 Expression and is a Potential PBMC-Based Biomarker for Coronary Artery Disease

Farshad Mirzavi et al. Safieh Ebrahimi Arezoo Rajabian Hossein Hosseini Behnam Alipoor

Abstract

Background:

Coronary artery disease (CAD) is the most common form of cardiac disease with high morbidity and mortality rates.

Objectives:

In this study, we evaluated the expression of miR-27a and miR-27b as biomarkers in peripheral blood mononuclear cells (PBMCs) of patients with CAD and investigated its correlation with cholesterol-efflux transporter, ATP-binding cassette transporter A1 (ABCA1).

Method:

This study was performed on 54 men with CAD and 51 healthy, sex- and age-matched control participants. The expression of miR-27a/b and ABCA1 genes in PBMCs were measured by quantitative real-time polymerase chain reaction (qRT-PCR). The protein expression of ABCA1 was assessed by Western blotting. Concurrently, the specificity and sensitivity of miR-27a/b was evaluated through receiver operating characteristic (ROC) curve. The significance level adopted in the statistical analysis was 5%.

Results:

We found that miR-27a and miR-27b expression were significantly increased, while both mRNA and protein expression of ABCA1 were markedly reduced in the PBMCs of CAD patients in comparison to non-CAD controls. miR-27a/27b expression was also shown to be inversely correlated with ABCA1. ROC analysis showed that the miR-27a had an area under the ROC curve (AUC) of about 92.6 (sensitivity 83.3٪ and specificity 86.6٪) and miR-27b had an AUC of about 93.0 (sensitivity 86.6٪ and specificity 80.0 (%, suggesting the diagnostic potential of miR-27a/b in CAD patients.

Conclusions:

Our data suggested a possible role of miR-27a/b in CAD pathogenesis. Additionally, we proposed that miR-27a/b expression in PBMCs may have potential clinical implications in the diagnosis of CAD patients, but further validations in large cohorts are required.

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Original Article

Evaluation of Frontal QRS-T Angle in Patients with Coronary Artery Ectasia

Mehmet Zulkuf Karahan et al. Adem Aktan Tuncay Güzel Fethullah Kayan Serhat Günlü

Abstract

Background:

Coronary artery ectasia (CAE) is defined by focal enlargement of the coronary artery exceeding 1.5 times the adjacent normal segment. CAE can often cause arrhythmias, heart failure, sudden death, and myocardial ischemia. Ischemia due to microvascular dysfunction may be responsible for the ventricular heterogeneity in CAE.

Objectives:

The aim of our study was to evaluate the frontal QRS-T angle in patients with CAE.

Methods:

Our study included 55 patients with CAE and 50 individuals in the control group. Demographic characteristics and electrocardiographic parameters were compared between the two groups. Categorical variables were compared using the chi-square test. Continuous variables were compared using unpaired Student’s t-test. P values < 0.05 were considered statistically significant. The frontal QRS-T angle was calculated from 12-lead electrocardiograms (ECGs) using the automatic report from the electrocardiography machine.

Results:

The average age of patients with CAE was 63.2 ± 3.4 years, with 18 women among them. The control group had an average age of 61.1 ± 3.2 years, with 28 women included. There was no significant difference in demographic parameters between the two groups. Compared to the control group, patients with CAE had significantly wider frontal QRS-T angle (p < 0.001), as well as longer QTmax duration, p = 0.002; Tp-Te interval, p = 0.02; and QT dispersion (QTd), p = 0.04.

Conclusion:

The frontal QRS-T angle can be calculated easily and time-efficiently using surface electrocardiography. In this study, we showed for the first time that the frontal QRS-T angle was significantly increased in patients with CAE.

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Original Article

The Relationship between CHA2DS2-VASc Score and Reperfusion Success in Elective Percutaneous Saphenous Vein Graft Interventions

Yücel Kanal et al. Kevser Gülcihan Balci Nezaket Merye Yaman Ídris Yakut … Mustafa Bilal Ozbay Orhan Maden

Abstract

Background

Patients with degenerated saphenous vein grafts (SVG) have a higher risk of developing no-reflow. The CHA₂DS₂-VASc score was established as a no-reflow predictor in patients with acute coronary syndrome (ACS).

Objectives

In our study, we aimed to assess the association between CHA₂DS₂-VASc score and no-reflow after the procedure and short-term mortality in patients with SVG who underwent elective percutaneous coronary intervention (PCI).

Methods

Our retrospective study comprised 118 patients who were divided into two groups according to the occurrence of the no-reflow phenomenon. The groups were compared on the basis of demographic characteristics, angiographic parameters, CHA₂DS₂-VASc scores, and outcome. A logistic regression analysis was additionally performed to determine the predictors of no-reflow. A p value of < 0.05 was considered statistically significant.

Results

Mean age of the participants was 66.4 ± 9.2 years, and 25.4% of them were female. Apart from the history of diabetes (p = 0.032), demographic data, blood parameters, ejection fraction, total stent length and diameter, medication use, median CHA₂DS₂-VASc score, and adverse cardiac events did not differ between the groups. In univariate logistic regression analysis, the presence of diabetes and stent length appeared to be associated with no-reflow, but not in multivariate analysis. The median CHA₂DS₂-VASc score was higher in non-survivors at 1-year follow-up (4.5 versus 3, p = 0.047).

Conclusions

In our study, we did not observe a significant relationship between no-reflow and CHA₂DS₂-VASc score. Larger studies are needed to reveal the indicators of improved post-intervention reperfusion in elective SVG PCI.

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Original Article

Quality of Life in Patients After Acute ST-Segment Elevation Myocardial Infarction

Bárbara de Matos Santos et al. Itana Samara Santana Guimarães Katia de Miranda Avena Ivan de Mattos Paiva Filho Pollianna de Souza Roriz

Abstract

Background:

ST-segment elevation myocardial infarction (STEMI) is the acute coronary syndrome with the highest severity and mortality. It can affect physical health and well-being of patients, and consequently their quality of life (QoL).

Objective:

To describe the QoL of patients at 30 days and 180 days after STEMI, focusing on sex differences and repercussions on physical and mental dimensions.

Methods:

Observational study with 174 STEMI patients included in the study on STEMI conducted in the city of Salvador, Brazil (PERSISST). The QoL of patients at 30 days (D30) and 180 days (D180) after the coronary event was assessed using the 12-item short form health survey (SF-12). Physical and mental components of QoL were calculated using the SF-12 OrthoToolKit. Descriptive analysis of data was made using the IBM SPSS software, version 25.0.

Results:

Mean age of participants at D30 and D180 was 57.1±11.4 years and 60.5±10.9 years, respectively, with a higher prevalence of men (55.8% and 56.8%). In general, patients had a poor QoL at both time points (scores 49.1±8.9 and 49.9±8.4, respectively). Analysis by sex, however, showed that men had a good QoL at both 30D (score 51.8±7.4) and 180 D (score 51.3±7.7), whereas a poor QoL was found among women at these time points (45.7±9.6 and 48.1±9.0, respectively). Men showed higher physical and mental health scale scores than women at both D30 and D180, and there was a greater impairment of the physical component in both sexes.

Conclusion:

Patients had poor QoL at 30 days and 180 days after STEMI, with a greater impairment of the physical component and a worse QoL perception among women than men at both time points.

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