Angiography – ABC CARDIOL

ABCIC

Editorial

"Triple Rule-Out": Including the Abdominal Aorta With a Clear Conscience?

Less is More – Less Radiation Dose, More Patient Safety

The main strength of the study lies in its methodological approach. The authors selected patients who had previously undergone the TRO CTA protocol including the abdominal aorta with full electrocardiographic synchronization. After obtaining consent, they performed a new examination using the partial electrocardiographic synchronization protocol, enabling a robust comparison through a “matched case-control” model. This approach minimizes bias related to anatomical and technical variability among different individuals.

The results were interesting. The dose reduction was significant: the mean effective dose of the protocol with partial ECG synchronization was 47.9% lower than that of the protocol with full synchronization (17.0 mSv vs. 32.6 mSv, p<0.001). It is noteworthy that this reduction in radiation dose was not accompanied by a compromise in image quality. The quantitative assessment of attenuation values in critical vascular regions – such as the ascending aorta, descending aorta, abdominal aorta, and pulmonary trunk – showed no statistically significant differences. Similarly, the subjective qualitative evaluation demonstrated equivalence between the two protocols in terms of image quality of the assessed anatomical structures.

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IJCS

Original Article

General Approach to Acute Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA): A Systematic Review

Marcos Aurélio Barboza de Oliveira et al. Alan Vinicius Gamero Ósti Bruno Vargas Teixeira Cavalheiro Déborah Barbosa Naves … Emanuelle Ribeiro de Oliveira Gabriel Freitas de Campos Gabriel Mael Sussuarana Silva Lobo Gabriely de Oliveira Marcela Paula Mainardi Marília Cardoso Guimarães Robert Filipe Barbosa Vilian Veloso de Moura Fé

Abstract

Background

Acute myocardial infarction (AMI) without obstructive coronary arteries (MINOCA) is a medical condition of great relevance, with clinical characteristics of AMI, but without evidence of coronary artery obstruction. The mechanism involved in the pathophysiology of the disease and its possible etiologies are important objects of study due to their impact on the morbidity and mortality of affected patients.

Objectives

The aim of this study was to systematically review MINOCA and its characteristics, with emphasis on the clinical profile of patients, etiology, pathophysiology, diagnosis, and treatment of the syndrome.

Methods

Relevant articles related to MINOCA were analyzed in the PubMed and LILACS databases. In the initial search stage, 619 eligible articles were obtained, with final inclusion criteria being: original systematic reviews with clinical, epidemiological, diagnostic, or treatment data on MINOCA, published in Portuguese or English, with an abstract, and a publication date limit of September 2020.

Results

A total of 10 articles classified as systematic reviews that considered clinical data on MINOCA were included in this review.

Conclusion

After analyzing various literature, the present study provided a tool to better understand MINOCA, not only regarding its casuistry but also in grouping parameters and information that contribute to a healthy approach to this clinical situation. It was possible to identify and better outline the clinical profile of patients who presented this condition and the use of appropriate tools for correct diagnosis and ideal treatment.

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ABC

Research Letter

Revascularization with Coronary Artery Bypass Grafting in Non-ST-elevation Acute Coronary Syndromes: A Snapshot of Randomized Trials and Registries

Josip Andelo Borovac et al. Jerko Ferri-Certic Dino Miric Jaksa Zanchi … Mislav Lozo Anteo Bradaric Konstantin Schwarz Chun Shing Kwok

A recent European Society of Cardiology (ESC) guidelines for the management of patients presenting with acute coronary syndromes (ACS) without persistent ST-segment elevation (NSTE-ACS) do not recommend routine pretreatment with a P₂Y₁₂ receptor antagonist in patients in which the coronary anatomy is undetermined, and early invasive management is planned (class recommendation III, level of evidence A). The rationale for such recommendation was mainly based on the results obtained from two large randomized trials, ACCOAST and ISAR-REACT 5, and analysis from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR)^, showing that administration of P₂Y₁₂ inhibitor before the knowledge of coronary anatomy in patients with NSTE-ACS did not improve ischemic outcomes and significantly increased risk of bleeding.

Some of the clinical concerns associated with upstream platelet inhibition in NSTE-ACS are based on the notion that such a strategy might be harmful in patients with other conditions mimicking NSTE-ACS, such as aortic dissection or may be at risk for major or fatal bleeding events such as intracranial bleeding. Likewise, NSTE-ACS patients who would need to undergo coronary artery bypass graft (CABG) surgery after their coronary anatomy is visualized by diagnostic coronary angiography might be at increased risk of bleeding complications and procedural delays due to receipt of P₂Y₁₂ inhibitor pretreatment since 3 to 7 days are required to allow for recovery of platelet function prior to CABG. Furthermore, there are complex discretion factors in real-life, such as surgical hesitancy or decline to operate on a patient on a current dual antiplatelet treatment (DAPT). It should also be noted that non-CABG-related bleeding is a relevant concern for clinicians, such as gastrointestinal bleeding or catheterization access bleeding, and these complications are likely to be more frequent with pretreatment use. Since the latest ESC guidelines state that “pretreatment strategy might be harmful to a relevant proportion “of such patients, we sought to determine what exactly is the proportion of patients with NSTE-ACS that were referred to CABG surgery following angiography and we report on the prevalence of high-risk features that might predispose them to a potential receipt of surgical revascularization.

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ABC

Original Article

Association of Paraoxonase-1 Genotype and Phenotype with Angiogram Positive Coronary Artery Disease

Sara Saffar Soflaei et al. Mojtaba Baktashian Kiana Hosseinpour Moghaddam Maryam Saberi-Karimian … Negin Kosari Seyed Mohammad Hashemi Mohsen Mouhebati Mahsa Amini Mashallah Dehghani Habibollah Esmaily Mahmoud Ebrahimi Homa Falsoleiman Abolfazl Nosrati-Tirkani Fatemeh Sadabadi Gordon A. Ferns Mansoor Salehi Alireza Pasdar Majid Ghayour-Mobarhan

Abstract

Background

It has been shown that increased serum PON1 levels are protective against several disorders. Several single nucleotide polymorphisms (SNPs) of the PON1 gene have been reported to be associated with serum enzyme protein levels and activity.

Objective

To investigate the association of SNPs of PON1 and serum paraoxonase activity with coronary artery disease (CAD).

Methods

A total of 601 unrelated patients who underwent coronary angiography including those who had >50% stenosis (N=266) and those with <30% stenosis (N=335) were studied. The Paraoxonase gene rs662 and rs840560 SNPs were determined using the ARMS-PCR method and the rs705379 SNP was genotyped using PCR-RFLP analysis. Serum paraoxonase activity was measured using paraoxon as a substrate. A p value of p<0.05 was considered as significant.

Results

Serum paraoxonase activity was not significantly different between the study groups. After adjustment for age, sex, hypertension, diabetes mellitus and dyslipidemia, the GG genotype and co-dominant model of rs662 was positively associated with a positive angiogram (respectively, OR=2.424, 95%CI [1.123-5.233], p<0.05, OR=1.663, 95%CI [1.086-2.547]). Serum paraoxonase activity was significantly higher in the G allele and GG variant of rs662, A allele and AA variant of rs854560 and C allele and CC variant of rs705379. The haplotype analysis has shown that the ATC haplotype was significantly more prevalent among the angiogram negative group. The analysis between groups indicated that the A allele of rs662 was significantly associated with lower paraoxonase activity in the positive angiogram group (p=0.019).

Conclusions

The presence of the G allele of the rs662 single nucleotide polymorphism is independently associated to increased risk of CAD.

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ABC

Original Article

Physiology or Angiography-Guided Coronary Artery Bypass Grafting: A Meta-Analysis

José Martins et al. Vera Afreixo Luís Santos Luís Fernandes Ana Briosa

Abstract

Background:

While invasive coronary angiography is considered the gold standard for the diagnosis of coronary artery disease (CAD) involving the epicardial coronary vessels, coronary physiology-guided revascularization represents a contemporary gold-standard practice for the invasive management of patients with intermediate CAD. Nevertheless, the long-term results of assessing the severity of stenosis through physiology compared to the angiogram as the guide to bypass surgery – coronary artery bypass grafting (CABG) are still uncertain. This meta-analysis aims to assess the clinical outcomes of a physiology guided CABG compared to the angiography-guided CABG.

Objectives:

We sought to determine if outcomes differ between a physiology guided CABG compared to an angiography-guided CABG.

Methods:

We searched Medline, EMBASE, and the Cochrane Library. The last date for this search was June 2020, and all of the previous studies were included. We conducted a pooled risk-ratio meta-analysis for four main outcomes: all-cause death, myocardial infarction (MI), target vessel revascularization (TVR) and major adverse cardiovascular events (MACE). P-value <0.05 was considered as statistically significant. Heterogeneity was assessed with Cochran's Q test and quantified by the I² index.

Results:

We identified five studies that included a total of 1,114 patients. A pooled meta-analysis showed no significant difference between a physiology guided strategy and an angiography-guided strategy in MI (risk ratio [RR] = 0.72; 95%CI, 0.39–1.33; I2 = 0%; p = 0.65), TVR (RR = 1.25; 95%CI = 0.73–2.13; I2 = 0%; p = 0.52), or MACE (RR = 0.81; 95%CI = 0.62–1.07; I2 = 0%; p = 1). The physiology guided strategy has 0.63 times the risk of all-cause death compared to the angiography-guided strategy (RR = 0.63; 95%CI = 0.42–0.96; I2 = 0%; p = 0.55).

Conclusion:

This meta-analysis demonstrated a reduction in all-cause death when a physiology guided CABG strategy was used. Nevertheless, the short follow-up period, small sample size of the included studies and the non-discrimination of the causes of death can largely justify these conclusions. Studies with an extended follow-up period of observation are required to draw more robust and definitive conclusions.

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ABC

Original Article

Does Mean Platelet Volume Decrease in the presence of Coronary Artery Fistula?

Isa Sincer et al. Yusuf Çekici Mehmet Cosgun Gulali Aktas … Yilmaz Gunes Emrah Erdal Asli Kurtar Mansiroglu Mehmet Inanır

Abstract

Background:

Coronary artery fistula (CAF) is an abnormal connection that links a coronary artery to a cardiac chamber or another major blood vessel. Several studies have shown the association between mean platelet volume (MPV) and cardiovascular diseases. In the literature, there is no previous study about the association between hematologic parameters and congenital CAF. For this reason, we aimed to investigate the association of MPV with CAF.

Methods:

70 patients with normal coronary arteries and 50 with coronary artery fistulas were included. Routine blood and biochemical parameters were measured before the arteriography. Differences between groups for continuous variables were analyzed with t- test or Mann-Whitney test. P values < 0.05 were considered significant. Regression analysis was used to find independent predictors of CAF.

Results:

Baseline patient demographics, including age and clinical risk factors, were similar between the groups. Compared to the control group, median (IQR) High-density lipoprotein cholesterol (HDL) levels were significantly higher (p=0.04) and MPV levels were significantly lower in the CAF group (8.84 ± 1.71fL vs. 10.43 ± 1.34, p < 0.001). In the multivariate analysis, only MPV was a significant predictor of CAF (p < 0.001, 95% CI for OR: 0.438 (0.306-0.629). A negative correlation was found between MPV and fistulae in Pearson's correlation test (r: -0.454, p < 0.001). An MPV level of < 9,6 fL showed sensitivity, specificity, positive predictive value and negative predictive value of 80%, 68%, 71% and 78% respectively (AUC = 0.766, 95% CI, 0.678-0.854) for the prediction of CAF.

Conclusion:

The present study suggests that MPV may decrease in patients with CAF.

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ABC

Artigo Original

Origin of the sinoatrial and atrioventricular nodal arteries in South Indians: an angiographic study

Lakshmi Ramanathan et al. Prakash Shetty Soubhagya R. Nayak Ashwin Krishnamurthy … Ganesh K. Chettiar Annamalai Chockalingam

BACKGROUND: To study the arterial supply of the conducting system and its correlation with the dominance of the coronary arteries in the South Indian population. OBJECTIVE: To determine angiographically the origins of the sinoatrial nodal artery (SAna) and atrioventricular nodal artery (AVna) in Indians. METHODS: The study included 300 consecutive patients (114 females, 186 males; mean age, 55 years) living in the southern coastal region of India, who underwent coronary angiography either for the symptoms of chest pain, angina pectoris or positive Treadmill Test. The angiograms contained both coronary arteries (right and left) in the right and left anterior oblique position. The origin of SAna and AVna from the coronary arteries was observed and correlated with the arterial dominance. RESULTS: The SA (sinoatrial) node was supplied by the right coronary artery (RCA) in 53% of the cases, by the circumflex (Cx) branch of left coronary artery (LCA) in 42.66%, and by both coronary arteries in 4.33% of cases. The AV (atrioventricular) node was also more often supplied by the RCA (72.33% of cases) than by the Cx branch of the LCA (27.66%), and surprisingly in none of the cases was this node supplied by both coronary arteries. CONCLUSION: The results of the present study may help cardiac surgeons, particularly in surgeries related to certain valvular disorders, due to the proximity of the nodal branches to the valve complex.

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ABC

Artigo Original

Exercise testing early after myocardial infarction: comparison with echocardiography, electrocardiographic monitoring and coronary arteriography

Wagner Aparecido Leite et al. Manoel Adan Gil Valter Correia Lima Bráulio Luna Filho … Denise Maria Servantes Angelo Amato Vincenzo de Paola Japy Angelini Oliveira Filho

BACKGROUND: Predischarge exercise testing early after myocardial infarction is useful for risk stratification, exercise prescription, and assessment of prognosis and treatment. OBJECTIVE: The objective of this study was to compare the findings of exercise testing early after myocardial infarction with those of echocardiography, electrocardiographic monitoring (24-hour Holter monitoring) and coronary angiography. METHODS: We evaluated 60 cases (mean age of 51.42 ± 9.34 years), of which 46 were males (77%). The symptom-limited maximal exercise test according to the Naughton protocol12 was performed between the sixth day of hospitalization and hospital discharge, with the patients on medication. During hospitalization, the patients underwent echocardiography, electrocardiographic monitoring and coronary angiography. The significance level was set at 0.05 (a = 5%). RESULTS: Exercise testing had a poor performance in the detection of multivessel coronary artery disease (sensitivity, 42%; specificity, 69%). No significant differences were found when the presence of ischemia on exercise test was compared with multivessel coronary disease, complex ventricular arrhythmias on electrocardiographic monitoring, and the finding of an ejection fraction lower than 60% on echocardiography (p = 0.56), as well as with the presence of multivessel lesions, complex ventricular arrhythmias on electrocardiographic monitoring and abnormal ejection fraction on echocardiography (p = 0.36). CONCLUSION: The presence of ischemia during exercise testing was associated with the occurrence of ventricular arrhythmias on electrocardiographic monitoring, with reduced ejection fraction on echocardiography, as well as with the presence of multivessel coronary lesions, which constitutes an indicator of a high coronary risk.

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ABC

Original Article

Comparative study of the use of diltiazem as an antispasmodic drug in coronary angiography via the transradial approach

José Ronaldo Mont'Alverne Filho et al. João Alexandre Rezende Assad Alexandre do Canto Zago Ricardo Leite Vieira da Costa … Antonio Guarany Mont'Alverne Pierre Mohamed Hassan Saleh Rodrigo Barretto Sérgio Luiz Navarro Braga Fausto Feres Amanda Guerra Moraes Rego Sousa José Eduardo Moraes Rego Sousa

OBJECTIVE: To evaluate the impact of the use, prior to the procedure, of injectable diltiazem to prevent complications. METHODS: Between September 2000 and July 2001, 50 patients underwent transradial coronary angiography and were randomized to receive placebo (GI) or diltiazem (GII) through a catheter inserted into the radial artery. All patients received isosorbide mononitrate. Ultrasound analyses of the radial artery were performed before examination, 30 minutes afterwards, and 7 days afterwards to evaluate the flow, the diameter, and the artery output. RESULTS: The radial artery diameter of GI was 2.4± 0.5 mm before the procedure and 2.3±0.5 mm after 30 minutes (NS), whereas in GII the diameter was 2.2±0.3 mm before the examination and 2.5±0.4 mm 30 minutes after it (P<0.001). Radial artery output in group 1 was 7.3±5.l2 mL/min before the examination and 6.1±3.5 mL/min 30 minutes after the examination (NS), and GII had an increase of 5.9±2.5 mL/min before examination to 9.05± 7.78 mL/min after the examination (P=0.04). Complications (spasm, occlusion, and partial obstruction) occurred in 4 patients (17.4%) in GI and did not occur in GII (P=0.04). CONCLUSION: The study suggests a decrease in vascular complications through the transradial access for coronary angiography with the use of diltiazem as an antispasmodic drug, resulting in the significant increase in the diameter of the radial artery and radial artery output.

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