Coronary stenosis – ABC CARDIOL

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Editorial

Cardiovascular Magnetic Resonance and Cardiovascular Computed Tomography in the Present and Future Cardiology

Modern non-invasive imaging techniques like cardiovascular computed tomography (CCT) and cardiovascular magnetic resonance (CMR) can diagnose and monitor a wide range of cardiovascular diseases with unprecedented accuracy and safety.^– With advances in the understanding of cardiovascular diseases and increasing availability of new and revolutionary therapies, detailed and quantitative information of disease stage have become crucial for the appropriate decision-making for each patient, which is one of the pillars of personalized medicine.

As an example, we can mention the high accuracy of CCT in the diagnosis and quantification of coronary atherosclerosis and stenosis ( ), and assessment of functional significance by the fractional flow reserve (FFR) technique. Considering recent knowledge of the role of characteristics of the plaque and the global burden of the atherosclerotic plaque involving the coronary tree on the prognosis of coronary artery disease (CAD), CCT has turned out to be a key tool in therapeutic decision making, be it for stenosis revascularization, be it for prevention of adverse cardiovascular events. Another example is the ability of CCT in monitoring the response of atherosclerotic plaques to advanced therapies, like those including PCSK9 inhibition by monoclonal antibodies or RNA interference.^{– , –}

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ABCIC

Original Article

Increased Wasted Myocardial Work as an Indicator of Significant Coronary Lesion

Márcio Mendes Pereira et al. Amanda Castro Barroso Marco Túlio Hercos Juliano Márcio Mesquita Barbosa … Gustavo Travassos Gama Rodrigo de Jesus Louzeiro Melo José Bonifácio Barbosa Carlos Alberto Vieira Gama José Xavier de Melo Filho Auridesio Cutrim de Araujo

Abstract

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.

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Editorial

Invasive Physiological Assessment: From Binary to Continuous

Daniel Chamié et al. Alexandre Abizaid

Described by Pijls et al., in 1993, and based on extensive validation and robust clinical data, fractional flow reserve (FFR) was incorporated into the guidelines of myocardial revascularization to guide the need for revascularization of angiographically intermediate stenosis in patients with stable coronary artery disease (CAD).^– The broadest arguments for this decision were: (1) by depicting a complex tridimensional structure as a planar silhouette coronary angiography suffers from well-known limitations, it presents large variability in estimating coronary stenosis severity, and it has low ability in predicting the functional significance of epicardial coronary stenoses, and (2) revascularization in stable coronary artery disease based solely on the severity of luminal narrowing, as determined by coronary angiography, does not improve clinical outcomes as compared to optimized medical treatment or versus revascularization of only physiologically significant lesions.^–

The central premise of invasive assessment of coronary physiology is to identify myocardial ischemia with superior spatial resolution (per vessel) compared to non-invasive methods (per territory), aiding in the identification of lesions (and, therefore, patients) that are more likely to benefit from revascularization. However, despite the clinical benefits and guideline recommendations, the FFR uptake in clinical practice remains low (< 10%) in most catheterization laboratories around the globe. Costs, time added to procedures, patient discomfort to hyperemic stimulus or contraindications to adenosine use, as well as difficulties in interpretation of physiological traces in certain anatomic situations (e.g., serial/diffuse stenosis), are some of the reasons for FFR underutilization.

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IJCS

Brief Communication

The Influence of Comorbid Conditions on Graft Stenosis in Patients with Coronary Artery Bypass Graft Operation

Turgut Karabag et al. Belma Kalayci Bahar Sahin Elif Coskun … Mustafa Umut Somuncu Mustafa Ozan Cakir

Abstract

The primary goal of coronary artery bypass grafting is to achieve complete revascularization with grafts that will remain patent throughout the patient’s lifetime. This study investigated the association between bypass graft patency and comorbidity burden determined by Charlson comorbidity index (CCI) among patients with previous bypass operation who underwent a control angiography. One-hundred and two patients who had undergone CABG in the past were included to the study. Critical stenosis was defined as 50% or greater coronary luminal obstruction of any coronary vessel or its lateral branch. Patients were divided into 2 groups group 1; critical graft stenosis; (54 pts; 41M, mean age 66.5 ± 7.8 years), group 2; graft patent (48 pts; 31M, mean age; 65.9 ± 8.2 years). Charlson comorbidity index (CCI) and modified CCI scores were used for detecting comorbidities. The comparison of continuous variables between the control and critical CAD groups was performed by the independent sample test. A p value less than 0.05 was considered statistically significant. The two groups were statistically similar with respect to demographic properties, time since bypass operation, cardiovascular risk factors, systolic blood pressure, heart rate, medications used, complete blood counts parameters, and lipid profiles. CCI was significantly higher in Group 1 compared to Group 2 (7.14 ± 2.02 vs 4.72 ± 1.58; p < 0.001). Modified CCI scores were also higher in Group 1 than in Group 2 (6.14 ± 2.02 vs 3.73 ± 1.60; p < 0.001). Graft occlusion was more common among patients with a high comorbidity burden. CCI scoring system may be helpful for determining patients at increased risk at both the preoperative and postoperative periods.

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ABC

Letter to the Editor

Prophylactic Left Internal Mammary Artery Graft In Mildly-Stenosed Coronary Lesions. Still an Open Discussion

Levent Cerit

I have read the article entitled “Prophylactic Left Internal Mammary Artery Graft in Mildly-Stenosed Coronary Lesions. Still An Open Discussion” by Evora et al.1 with great interest, recently published in Arquivos Brasileiros de Cardiologia. The investigators reported that the idea of a prophylactic left internal mammary artery (LIMA) on left anterior descending in mild-stenosed vessels is not confirmed yet by clinical evidence.

Berger at al. reported that all moderate coronary lesions should be LIMA grafted during primary coronary bypass surgery.

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ABC

Editorial

Prophylactic Left Internal Mammary Artery Graft In Mildly-Stenosed Coronary Lesions. Still An Open Discussion

Paulo Roberto B. Evora et al. Livia Arcêncio André Schmidt Alfredo José Rodrigues

Introduction

The main advantages of CABG with the left internal mammary artery (LIMA) have been well established since the 80s and can be enumerated as follows.

It has been well established that coronary venous grafts in arteries with moderate atherosclerotic lesions (<70%) had early occlusion mainly due to flow competition with the native coronary circulation. Otherwise, to graft a moderately stenosed coronary vessel with LIMA remains debatable, keeping the question by Hayward and colleagues open: "Should all moderate coronary lesions be grafted during primary coronary bypass surgery?". However, controversy exists whether LIMAs should be used to bypass coronary arteries with noncritical stenoses.

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Artigo Original

Frequency of acute plaque ruptures and thin cap atheromas at sites of maximal stenosis

Fabio Tavora et al. Nathaniel Cresswell Ling Li David Fowler Allen Burke

BACKGROUND: There have been few autopsy studies relating sites of thin cap atheroma (TCFA) to sites of acute plaque rupture in culprit arteries, and sites of maximal narrowing in non-culprit arteries. OBJECTIVE: We aimed to quantify and locate the frequency of TCFA related to the sites of maximal stenosis in atherosclerotic plaques. METHODS: We studied 88 hearts in victims of sudden death dying with coronary thrombus overlying acute plaque rupture. Thin cap atheromas were defined as fibrous cap < 65 microns overlying a necrotic core. Percent luminal narrowing was determined at the sites of plaque rupture and thin cap atheromas. RESULTS: There were 81 men and 7 women, mean age 50 years ± 9 SD. The plaque rupture was the site of maximal luminal narrowing in 47% of culprit arteries. TCFAs were present in 67 hearts (83%). Of these, 49 (73%) demonstrated TCFAs in the culprit artery; 17 (25%) in the culprit artery only, 32 (48%) in the culprit artery and in a non-culprit artery, and 18 (27%) only in a non-culprit artery. In non-culprit arteries, TCFAs represented the maximal site of stenosis in 44% of arteries. The acute rupture site is the site of maximal luminal narrowing in the involved vessel in 47% of hearts from patients dying with acute plaque rupture. CONCLUSION: These data may suggest that luminal narrowing is not a reliable marker for TCFA.

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Artigo Original

Acute coronary syndromes in the absence of significant coronary artery disease

Maria das Graças Viana Pinheiro et al. Alvaro Rabelo Jr. Rogerio Santos de Jesus Luciana Cunha Nascimento Ursula Maria Moreira Costa

OBJECTIVE: To assess the clinical characteristics, evolution, and in-hospital complications of patients with acute coronary syndromes (ACS) in the absence of significant obstructive coronary artery disease (CAD). METHODS: Cross-sectional study of patients hospitalized from August 1996 to March 2002 with acute coronary syndrome, with or without an elevation in the ST segment, and with (= 50%) or without (<50%) significant coronary stenosis. Their clinical and demographic characteristics and their in-hospital complications were analyzed. RESULTS: Of the 1351 patients admitted with acute coronary syndrome, 28% had an elevation in the ST segment and 72% had no elevation. The patients with acute coronary syndrome with no elevation in the ST segment and no significant coronary obstruction were younger, predominantly females, and had a lower frequency of dyslipidemia, previous coronary arterial disease, diabetes mellitus, smoking, and systemic arterial hypertension, when compared with those with significant obstructive lesion. Among the individuals with acute coronary syndrome and an elevation in the ST segment, smoking was the most prevalent risk factor in patients with nonsignificant obstructive lesion. In regard to complications, recurring ischemia, congestive heart failure, and arrhythmias were more frequent in patients with acute coronary syndrome with no elevation in the ST segment and no significant obstructive coronary lesion. CONCLUSION: Patients with acute coronary syndrome with no elevation in the ST segment and with nonsignificant obstructive coronary lesions are younger, predominantly females, have a greater frequency of risk factors for coronary arterial disease, and a lower incidence of complications as compared with patients with significant obstructive coronary lesion.

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